Practice with rhetorical terms. You should be able to point to the following in
this piece:
* Rhetorical question
* narration
* exemplification
* description
* paraphrasing
The mistakes doctors make
Errors in thinking too often lead to wrong diagnoses
By Dr. Jerome Groopman | March 19, 2007
Dr. Jerome Groopman is chief of experimental medicine at Beth Israel Deaconess
Medical Center and a staff writer for The New Yorker. A more extensive look at
these ideas appears in his new book "How Doctors Think."
Five years ago, a woman named Leslie developed indigestion, abdominal discomfort,
and, occasionally, diarrhea. She has just given birth to her third child, and life was
understandably hectic at home. Her primary-care physician gave her antacids, but
this afforded only slight relief.
"I feel really different. Something has changed in my body," Leslie told her doctor.
But nothing abnormal was found on her physical examination or on routine tests.
Leslie was sent to several specialists, and before each visit her primary-care doctor
informed the consultants that Leslie was under "a lot of stress and seems anxious,
and depressed."
"Nothing is physically wrong," the doctors reassured Leslie. An antidepressant was
prescribed, but it did not ameliorate her condition.
Some four years later, Leslie felt dizzy and nearly fainted in the street. Her husband
drove her to the local hospital, where she was found to be severely anemic. X-rays
and scans showed a large mass where the small intestine meets the colon. Clearly,
the tumor had caused her previous problems.
Leslie is in her early 40s, an intelligent and thoughtful woman who told me her story
in a clear and organized way. "I felt like I must be losing my mind," she said when
recalling how her symptoms had been attributed to "stress and anxiety," and treated
with an antidepressant. Upon reviewing Leslie's medical records, I found a blood
test ordered by one of the specialists several years earlier that had been clearly
abnormal and indicative of an intestinal tumor called a carcinoid. Her symptoms
were consistent with this type of endocrine tumor, and, indeed, this proved to be the
diagnosis at surgery.
Misdiagnosis occurs in 15 to 20 percent of all cases, according to some research, and
it is estimated that in half of these, serious harm occurs.
Why do we as physicians miss the correct diagnosis? It turns out that the mistakes
are rarely due to technical factors, like the laboratory mixing up the blood specimen
of one patient and reporting another's result. Nor is misdiagnosis usually due to a
doctor's lack of knowledge about what later is found to be the underlying disease.
Rather, most errors in diagnosis arise because of mistakes in thinking.
Physicians diagnose diseases based on what is called "pattern recognition."
We draw bits of information from our patients' symptoms, our findings on
physical examination, the laboratory tests, and X-ray studies the way a magnet
pulls from all directions. To form patterns in our minds, we use shortcuts in
thinking, so called "heuristics." Usually, a doctor generates one or two
hypotheses about what is wrong within the first minutes of seeing the patient
and listening to his or her story. Often, we are correct in these rapid
judgments, but too often we can be wrong.
Physicians are rarely taught about pitfalls in cognition. During their training, they
work as apprentices to senior doctors. They learn largely by doing. In today's
medical system, where there is intense pressure to see as many patients as possible,
the quick judgment is often rewarded.
Unfortunately, working in haste is a setup for errors in thinking.
Only very recently have medical educators begun to focus squarely on the problem
of misdiagnosis, why it occurs, and what might be done to prevent it. It turns out
that errors in thinking do not occur in isolation, but usually arise from a cascade of
sequential cognitive mistakes.
I only learned this recently when I realized I did not know how I think; in fact, when
I asked other clinicians how they succeeded or failed in making a diagnosis, very few
could explain how their mind works to decipher a patient's problems.
Let's deconstruct Leslie's case. Yes, the arrival of a third child can cause stress in a
family. This truth strongly colored the physicians' impressions, so they made what is
called "an attribution error." This involves stereotyping -- in Leslie's case , casting
her as an anxious and somewhat depressed and distraught postpartum woman. The
diagnosis of indigestion and abdominal discomfort with occasional diarrhea was too
quickly fit into the pattern of a stress-related condition.
The doctors fixed on this diagnosis, so called "anchoring" where the mind attaches
firmly to one possibility. Anchoring so tightly to one diagnosis and not broadly
considering others is called "premature closure." Even when, later in Leslie's
evaluation, a blood test result was obtained that was very abnormal, it was not
sufficiently considered; no one involved in her case could lift their mental anchor
and comprehensively explore other possibilities.
Discounting such discrepant or contradictory data is called "confirmation bias" -the mind cherry-picks the available information to confirm the anchored
assumption rather than revising the working diagnosis.
When I called one of Leslie's doctors, he was crestfallen that he had missed what
was wrong. I knew all too well his feeling. Throughout my career I have made
cognitive mistakes, some of them originating from an attribution error.
All of us as physicians are fallible, and while it is unrealistic to imagine a perfect
clinical world, it is imperative to reduce the frequency of misdiagnosis. I believe all
health professionals should learn in-depth about why and how and when we make
errors in thinking, and I also believe that if our patients and their families and
friends know about the common cognitive pitfalls, they can ask specific questions to
help us think better.
We can interrupt the cascade of cognitive mistakes and return to an open-minded
and deliberate consideration of symptoms, physical exams , and laboratory tests -and in this way close an important gap in care.
Leslie was lucky, by the way. Her cancer turned out to be treatable, and she is doing
fine.
Sample Option 1: Two SQUAAT paragraphs joined together
At the end of Peter Shaffer’s Equus, the psychiatrist Dysart tells Alan that he
is going to “cure” him of his love and fear of horses. Dysart says to the audience, “I’ll
take away his field of ‘Ha Ha,’ and give him Normal places for his ecstasy – multilane highways driven through the guts of cities.” (109). Put another way, Dysart will
remove from Alan’s life his special ritual, with all its strange religious and sexual
connotations, and will replace that ritual with the ordinary world, filled with boring
old things like highways and convenience stores. Dysart’s metaphor about the roads
being driven through the “guts” of cities seems interesting because it suggests a
level of violence and connects to earlier parts of the play in which Dysart imagines
cutting open children and removing their organs. The violence of this image
suggests that Dysart is worried that he is doing real harm to his patients as he tries
to “cure” him. It also seems important to note that Dysart is saying this to the
audience. In many ways, they are the representatives of the Normal in this play and
it is like Dysart is pleading with them to recognize all the terrible things about the
normal world. With this ending, Shaffer seems interested in questioning whether it
is worth it to exchange our deepest passions to conform to the normal world.
While Peter Shaffer’s play is all about “curing” the abnormal world, Adrienne
Rich’s poem “Aunt Jennifer’s Tigers” seems to celebrate the exotic, interior world of
Aunt Jennifer. In lines 5 through 8, the speaker of the poem describes how her Aunt
Jennifer’s hands are weighed down by “Uncle’s wedding band” but that when she
sews the tiger tapestry her fingers “flutter.” The verb “flutter” implies that when
Aunt Jennifer is making her special tigers, she is almost free of the oppressiveness of
her marriage. Even though Rich’s poem, which is titled after Aunt Jennifer’s tigers
rather than just Aunt Jennifer, seems to celebrate Aunt Jennifer’s freeing
imagination, it seems worth noting that more of the images in these lines suggest
that Aunt Jennifer is trapped. The needle is “hard to pull” and the ring sits “heavily
upon her hand.” Through these descriptions Rich is showing how marriage can
oppress women’s most vital imaginations.
Sample Option #2: SQUAAT and then SOURCE paragraph or vice versa
Jerome Groopman, chief of experimental medicine at Beth Israel Deaconess
Medical Center, argues doctors need to slow down and be aware of common
cognitive errors they can make. In “Errors in thinking too often lead to wrong
diagnoses,” Groopman illustrates how simple errors in thinking lead to the 15 – 20%
of misdiagnosis errors that occur, some of which have very serious consequences.
One particular kind of error involves focusing too much on common patterns.
Groopman tells the story of a woman named Leslie, who has just had her third child
and who comes into the ER with abdominal problems. Groopman writes, “Yes, the
arrival of a third child can cause stress in a family. This truth strongly colored the
physicians' impressions, so they made what is called "an attribution error." This
involves stereotyping -- in Leslie's case , casting her as an anxious and somewhat
depressed and distraught postpartum woman.” Put another way, doctors focused
strongly on the fact that the woman had jus had a third child and they used that fact
to determine how they thought about the rest of their problem. Attribution errors
occur when doctors “attribute” too much to one particular detail. This is sort of like
when you meet a new person focusing on their nike sneakers and assuming they are
athletic and then asking them questions only related to sports. Groopman shows
just how dangerous this kind of error can be.
In a similar way, the speaker in Yusef Komunyakaa’s poem “We Never
Know” seems to fixate on a few key details about the person he has killed in battle.
In lines 5 – 7, Komunyakaa describes a man that either he or his platoon has just
shot. As he approaches the man’s body, he notices that the man is surrounded by a
“blue halo / of flies” (5 – 6). This image suggests that he sees the dead man as
somewhat heavenly, describing him as having an object associate with angels and
heaven. Perhaps, this heavenly halo means that the speaker has realized that he has
killed someone who was not, in fact, bad. Or maybe the description just speaks to a
certain sense of guilt the speaker feels. It is also interesting how the peaceful image
of the halo is almost immediately replaced by an image of destruction, as the flies
scavenge for flesh. This image mirrors war itself, where moments of peace can
quickly become deadly. Komunyakaa’s strong focus on details like the halo turning
into flies suggests that in war, morality and right and wrong are become very
complicated for soldiers and can change in an instant.