Getting into doctor’s mind

D octors may not be the brainiest in society; yet the fascinating ways in which they think and make decisions has been the subject of interesting research. A book by Dr Jerome Groopman attempts to analyze it.

There are some parts of the brain that a doctor uses preferentially over others, memory being the most important to start with. It begins from the time a youngster thinks of taking the entrance exam to medical school – he is required to read, retain and reproduce a large number of factual information and names of body parts and functions. Unlike the engineering, management or law students, medical aspirants are hardly required to use mathematical problem solving, creative thinking, logic or thinking out of the box. But ask them names and profiles of thousands of organs, tissues, cells and drugs, and they will have it on their fingertips!

As they progress to the next phase of clinical work, doctors learn to recognize “patterns” of symptoms and signs in patients, and try to fit these into the puzzle board of diagnosis. Chest pain accompanied by sweating would suggest a heart attack, or jaundice with loss of appetite would fit the pattern of “hepatitis”, for instance.

When the doctor starts maturing as a clinician, he starts to pick up a feature called “probabilistic” thinking, wherein the patient’s profile starts becoming a key factor rather than the symptoms alone.

To take the example of chest pain again, he starts recognizing that the same symptom in a young 20year-old girl is almost always of neuro-muscular origin and hardly ever from the heart, while in a 50-year-old overweight smoker with high BP, it is very likely to be a heart attack, requiring immediate referral to a cardiac ICU.

With further development in his career, he starts factoring in several aspects of his patient in the process of decision-making. In other words, it is at this stage that he starts incorporating the “art” of decision making to the text-bookish science that he has crammed. Does the vegetable vendor who has come down with cough and fever for 2 days after getting wet in the rain require to be subjected to a CT scan of the chest or would an antibiotic suffice? Does the 16-yearold schoolgirl with recent onset vomiting prior to the board exams require an endoscopic examination right away? What if she had had these symptoms last year too when she was stressed before her final exams?

The mature doctor then is not just a repository of facts, information and knowledge. It is the unconscious assimilation of years of experience, marinated with a sensitive understanding of his patient’s concerns and constraints, and with an iota of intuition thrown in, that make him take decisions that posterity usually seems to approve.

In present times, things get pretty amusing. I often get patients demanding investigations to find out what the reports say and that would explain their symptoms. And then the doctor has to explain why the reports don’t give a clear diagnosis!

Good clinical decision making, like good wine, matures over time. Knowledge alone does not make a good doctor; the flavor matters!