How Doctors Think, a book review

Bought this book based on several reviews. I was especially interested in the topic of cognitive and affective processes influencing decisions in doctors. At first a little disappointed because the book has a lot of anecdotes and interviews with doctors about their mistakes and how they learn from these mistakes. These anecdotes and interviews are interesting reading and very well written. After about a third the anecdotes become more interesting to me because they are linked with the cognitive and affective complications influencing decision making in doctors.

Some examples of these cognitive and affective processes influencing decision making

  • Emotions either negative of positive towards a patients can influence the doctors thinking. Emotions can blur a doctor’s ability to think and listen. Not that doctors shouldn’t have emotions but they should be aware of these emotions and how they can influence their decision making. In psychiatry these emotions are named transference and counter transference.
  • Stress also influences the decision making, to much or to less stress have a negative influence of the decision making in doctors. This is also know as the Yerkes-Dodson Law
  • Availability, or the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind, e.g. overseeing pneumonia during a influenza pandemic.
  • Confirmation bias or confirming what you expect to find by selectively accepting or ignoring information
  • There are doctors who easily think in obscurities, ignoring the most simple diagnosis as well as doctors who show signs of “zebra retreat”. The latter are doctors shying away from a rare diagnosis. Health care costs are often a motivation for “zebra retreat”
  • Diagnosis momentum or becoming to fixed on a diagnosis. Sometimes the diagnosis is so fixed in the thinking of a doctor such that new or incomplete evidence doesn’t influence this.
  • The hardest problem is dealing with uncertainty. It takes time to reflect on the uncertainty, then restructure the problem and try again. More immature ways of dealing with uncertainty is is black humor, making bets, magical thinking.
  • Commission bias or the tendency toward action rather than inaction. Mostly motivated by overconfidence, ego inflation, but also when a physician is desperate and gives in to the urge to “do something”

It also has some nice explanation of research on radiologists. Should they look at the broad picture, go with the first impression or should they use a checklist and describe every item on that list. Moreover, how far or near to the clinical question when present should the radiologist go in his description of the procedure?

The last part of the book is about drug companies influencing doctors. Even trying to influence guideline committees and opinion leaders all for the sake of money.

For patients the book can be of value since it teaches them tricks, questioning in order to help the doctor improve his or hers reasoning. Patients can help doctors not to make cognitive mistakes by simple questioning thereby influencing the cognitive processes. For instance the question: What’s the worst thing this can be?, can help the doctor to broaden his view, think more open about a problem, not jump to fast to conclusions. Another example is the question: What body parts are near where I am having my symptoms?

In short a very well written book for physicians and patients. Not a short textbook about cognitive and affective influences on decision making by physicians.