Physicians are often forced to make critical treatment decisions in states of partial ignorance. Groopman shows us how easily their small errors in judgment can cause harm, and he advances a sensible prescription for avoiding it. The physician can’t rely solely on his own knowledge or intuition, he writes, but must join “his intuition with that of his patient.” The characters in Groopman’s clinical tales (real doctors given fictional names and affiliations) are constantly forgetting that lesson. When the author’s own 9-month-old son develops a life-threatening intestinal blockage, a complacent New England pediatrician brushes it off as a viral infection and suggests giving him Tylenol. Groopman and his wife take their baby to the hospital anyway. There a young resident correctly diagnoses the problem as an intussusception–and nearly kills the child by declaring that surgery can wait until the next day. Fortunately, the couple manage to summon a specialist who can overrule him. In other stories we see a cleaning lady’s acute leukemia written off as routine asthma. We see the effects of an internal hemorrhage dismissed as side effects of Prozac. And we see a prominent hematologist push a patient toward a life-threatening “unmatched” bone-marrow transplant–despite hints that his mysterious blood disease doesn’t originate in the marrow.
Only rarely do these missteps stem from a lack of technical knowledge. More often they reflect simple inattentiveness. Marianna Montero knows something is “really, really wrong” when her mother, the cleaning lady, develops a chronic, debilitating fatigue and her breathing becomes increasingly labored. Yet instead of running the blood test that would detect her raging leukemia, an HMO doc reflexively dashes off an asthma prescription.
Equally dangerous is the tendency–hardly unique to physicians–to place too much faith in one’s own well-honed instincts. Knowing that blood cancers can cause harmless red skin nodules called chloromas, one specialist assumes the spots under a leukemia patient’s chin are nothing more than that. By questioning that assumption and testing the nodules, Groopman discovers that they’re packed with a TB-like bacterium that can invade the brain, lungs and liver if left untreated. “Doctoring [is] a balance between the sixth sense of intuition and the tedious reiteration of diagnostic lists,” he observes. “You don’t have to be brilliant to be a competent doctor, but you [do] have to be thorough.”
The tales in “Second Opinions” sometimes veer toward score settling and self-justification. While other physicians are often “condescending” or even “loathsome,” Groopman portrays himself as ever reasonable and “passionate about the care of patients.” But his passion is genuine, and often beautifully expressed. He shows us how critical it is for doctors to embrace their patients as collaborators, and to scrutinize their own assumptions at every turn. In laboratory science, he observes, failing to re-examine your initial hypothesis in the light of conflicting evidence can run an experiment into the ditch. The same is true in clinical medicine. The difference is that “you may not have a chance to try again if you fail.” If only every doctor were so wise.
