The Thinker Behind How Doctors Think
An interview with Dr. Jerome Groopman
Communications skills are “central to clinical competence,” he says – so why are they often lacking?
Few writers can capture the complexity of a doctor’s role as well as Jerome Groopman. He has served as a staff writer for The New Yorker, and written four books about medicine: “The Measure of Our Days” (1997), “Second Opinions” (2000), “An Anatomy of Hope” (2004) and “How Doctors Think” (2007). Not bad for a side career.
First and foremost, Dr. Groopman is Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston (and a prominent researcher in cancer and AIDS), and a professor of Medicine at Harvard Medical School.
In his New York Times review of “How Doctors Think,” the late Michael Crichton, another doctor-turned-writer, noted that Dr. Groopman calls for patients to be active participants in their care. Yet there’s a paradox, wrote Dr. Crichton: “Although the medical profession has long recognized that doctors communicate poorly with patients, physicians receive little training to improve that interaction. Historically, medical education has regarded communication skills with an indifference that approaches contempt.”
For this installment of Dialogue’s continuing series on communications, we spoke to Dr. Groopman. How does he think doctors rate when it comes to communications? What are the obstacles to communicating well? How does he define great medical service? And why was being a patient his best education?
Dialogue: If doctors and their patients each had to rate the importance of qualities in a doctor – what’s actually important to patients, and what doctors think are most important – would the lists match?
Groopman: If you ask patients what they think of their doctor, they’d say things like “He pays real attention to me,” or “She explains things,” or “He’s caring and compassionate.”
It’s the emotional dimension, the sense of being the focus of the physician’s attention and engaging in a genuine dialogue. Those aspects of physician practice are high on the list of patients.
Dialogue: What do doctors rank in importance?
Groopman: Clinical judgment would probably be number one. Doctors, understandably, tend to focus on clinical competency, in a strictly diagnostic-treatment context – what’s the best way to figure out an illness, and what informs choices of therapeutic options?
Dialogue: Is communications actually a clinical skill?
Communication skills are central to clinical competence. That truth hasn't yet filtered widely through the culture of medicine.
Dialogue: You’ve cited the work of Debra Roter and Judith Hall, from Johns Hopkins and Northeastern, who touch on this very topic.
Groopman: They’ve analyzed thousands of videotapes of physician-patient encounters. The conclusion is that communication skills are central to clinical competence. That truth hasn’t yet filtered widely though the culture of medicine. We have the stereotype of the brilliant surgeon who hardly talks and doesn’t explain, but who saves your life.
Dialogue: Wouldn’t many doctors say that’s the bottom line?
Groopman: Being able to explain something in clear and accessible language means you really understand the problem and have thought it out deeply. It means you have the biological and clinical underpinnings for your diagnosis and treatment.
Dialogue: Does anything in medicine work against good communications?
Groopman: There’s enormous pressure on efficiency. The idea is you can see more patients in less segments of time and end up with the same outcomes.
Dialogue: Is that possible?
Groopman: It depends on what you mean by “outcome.” Certainly, the experience of illness, and the whole issue of patient adherence to advice is not well served by this ever diminishing time frame of the doctor-patient encounter.
Dialogue: What kind of medical practice do we end up with?
Groopman: Lowest common denominator medicine.
Dialogue: Other fields have time and workload pressures. What else is at play in medicine that might diminish the importance of communications?
Groopman: In the U.S., and probably Canada has wrestled with this too, powerful financial incentives are being applied in what are essentially social experiments, for so-called “pay for performance.” Communications skills are difficult to measure. Because of that, they’re given no space in the financial reward system. A quality physician is one who checks off the boxes. Whether he or she communicates well, whether patients really understand the nature of their illness – all of the compassionate things that make medicine a calling, and not a business – none of that is accounted for.
Dialogue: And if these so-called “softer” skills aren’t measured?
Groopman: My concern is that given that these are seen as being nebulous, difficult to quantify, they are essentially ignored.
Dialogue: Is that changing? In discussions of health-care reform – whether in Canada or the U.S – does it seem like communications is being valued more?
Groopman: Everything is metrics now, from the policy planners.
They give lip service to this stuff. President Obama says, for example, that doctors should be healers, not bean counters and paper pushers. But in all of the health-care legislation being debated, find where being a healer is rewarded.
Dialogue: In “Second Opinions”, you write about being a patient yourself, when you developed an ache in your hip while training for the Boston Marathon. You wanted an immediate remedy, had surgery for a bulging disc, and ended up with a lingering problem. In the first line of the book, you made a bold comment.
Groopman: That I learned more in the months of being a patient than I did in all my years of medical school.
Dialogue: What lessons did you learn?
Groopman: It was a completely different experience being on the other side. What appears to be apparent and direct and straightforward for a physician is often fraught with complexity and uncertainty for a patient. How a physician assesses the risks and benefits of a particular treatment, say, is quite different than how a patient does.
Dialogue: How do you bridge that gulf in perception?
Groopman: Through dialogue. If you look at every guideline, in the fine print it says that recommendations must fit the patient’s preferences and goals; the only way to draw those out is engaged conversation.
A doctor needs time to have the opportunity to ask open-ended questions rather than closed-ended questions, so one can hear the patient’s story. Again, that gets a lot of lip service but no concrete rewards.
Dialogue: Can being a patient – going through an injury or illness – make you a better doctor?
Groopman: I remember as an intern and resident, patients would come into emergency with severe back pain, and half the time people would shrug and say they were a bunch of slackers and malingerers who wanted to get out of work. They had no idea. Until I injured myself, I had no concept of what it was like to struggle with debility. But you shouldn’t have to have every disease in the world in order to develop that empathy.
What appears to be apparent and direct and straightforward for a physician is often fraught with complexity and uncertainty for a patient.
Dialogue: Are medical schools preparing doctors from an interpersonal or communications skills standpoint?
Groopman: It’s a mixed bag. You have more attention on this aspect of medicine, but once people go into residency and out into the world, with all of the time pressures, well, we’re all products of our environment. If the environment doesn’t accommodate or support this, it’s awfully hard to sustain it.
Dialogue: When a customer has an issue with the service they’re receiving, they’re expected to provide feedback. That’s harder for patients to do. So how can doctors accurately judge their performance regarding “customer service”?
Groopman: That’s complicated. Feedback is very irregular. Some hospitals here have “secret shoppers,” but that’s mostly related to how long you waited. The Internet is also proliferating with doctor rating services. The problem is there’s no editorial control. You can get someone who makes a really cogent critique, that a physician didn’t communicate properly or seemed heartless, or you can have the most compassionate doctor in Canada maligned [unfairly] by someone.
Dialogue: If a doctor-patient relationship has some problem areas – say an issue with the doctor’s attitude – do patients have an idea of what to do about it?
Groopman: Patients almost always blame themselves for the doctor’s negative attitude. But when I ask fellow doctors what they would do if they were a patient, and they felt that their doctor was acting in a dismissive or negative way, every single doctor I spoke to said that he would find another physician.
Dialogue: So doctors themselves recognize that “the customer is always right” – at least when they themselves are the customer. Should the onus, then, be on the doctor to draw our what needs to be said during the patient encounter, or to clear the air? Or is the patient ultimately responsible?
Groopman: The last thing you want is an arm wrestle. It’s a matter of training physicians to ask the questions. Is there anything you need to tell me? Is there anything you’re uncomfortable about? Is there anything you want me to explain better? Use gentle language. That gives permission to the patient to provide constructive feedback.
Dialogue: Are we back to the issue of time constraints?
Groopman: The problem is when you ask those questions at minute 16 of an 18-minute clinic visit, you’re opening up another 20 minutes of discussion. Which may well be needed. But your practice manager will want to guillotine you.
Dialogue: If you’re the patient with the doctor, you’re okay with that. If you’re still waiting to see the doctor, it’s a different story.
Groopman: The question is how to apportion time, and that just isn’t amendable to easy system solutions.
Dialogue: You’ve cited a statistic that says most doctors interrupt a patient 18 seconds after they start talking. Are doctors even aware of this?
It’s an anchoring bias. Dr. Donald Redelmeier at Sunnybrook in Toronto has done extraordinary work around this. We tend to jump on the first bit of information that’s offered to us. So if you say, “What’s wrong?” and the patient begins by talking about a headache, immediately you jump “Headache!”
Dialogue: And that cuts off the patient’s story.
Groopman: You won’t even get to the pain in their abdomen, because all you’re doing is pursuing closed-ended questioning around headache.
Dialogue: So that’s part of what accounts for interruptions. Why else do they occur?
Groopman: Because of the time pressure, when someone gets tangential, there’s a skill to bring them back to mainstream of the problem. So you may need to interrupt.
Dialogue: How would you define bad doctor-patient communications?
Groopman: When the doctor doesn’t even look at you. A lot of doctors are just filling out a template, hardly looking up. That doesn’t make for constructive, open-ended dialogue. Number two, when doctors shoot from the hip and provide shotgun answers.
Dialogue: And the best doctor-patient communications?
Groopman: When people keep going back and revisiting parts of your history that can yield important clues.
Dialogue: Which gets back to your assertion that communications is a clinical skill. In “How Doctors Think”, you cite a study of 100 incorrect diagnoses. It found that inadequate medical knowledge was the reason for error in only four instances. So doctors don’t miss diagnoses because of ignorance, but because, as you say, they fall into cognitive traps.
Groopman: My wife, Dr. [Pamela] Hartzband, and I write a column for the American College of Physicians called “Mindful Medicine,” published in the ACP Internist. We’re in contact with physicians across the U.S., and hear about cases and diagnostic challenges. We heard from an endocrinologist in the Philadelphia area. He saw a man of about 80, who had seen four specialists because he told them he had “poor stamina.” So he had a cardio workup, and a pulmonary workup, and an endocrine workup, which costs a fortune.
Someone found that he had mildly low testosterone, which is a common finding in an older man, and probably not meaningful. So they sent him to yet another endocrinologist. This doctor asked him “What do you mean by ‘stamina’?”
Dialogue: So he started with a simple, open-ended question. Which led to what?
Groopman: The man pointed to his legs, and said that when he walks on the golf course, he gets pain and has no stamina in his legs. It turned out that he had poor blood flow. Just knowing what questions to ask would have saved three months of doctors’ visits and thousands of dollars in medical costs. And that’s not going to come out of an algorithm.
Dialogue: What ultimately defines an ideal performance by the doctor? What outcome do you want?
Groopman: A good job has dual components. You’ve addressed the physical, the clinical dimensions of illness. And you’ve taken into account the patient’s emotional, if you want to say spiritual, experience of suffering and dealing with adversity. If we can be poetic, you’ve cared for the patient body and soul.