The Best Medicine

Jerome Groopman | Posted on 09/01/09

My view of wisdom in medicine, perhaps ironically, comes not from a scientific treatise or clinical tome. Rather, it derives from words that I have heard and repeated since childhood but only after decades of clinical practice realized how they apply to the care of patients. In the traditional daily Jewish prayer called the Amidah, we give thanks to God, saying, “You grace humanity with knowledge and teach mortals understanding. Grace us with knowledge, understanding, and discernment that come from You.” Other traditions also view wisdom as a divine blessing, but one need not be religious or schooled in sacred texts to appreciate how the progression of terms in the prayer — knowledge, understanding, and discernment — maps a path to wisdom.

Wisdom begins with knowledge, the mastery of facts and findings in a discipline. In modern medicine, our knowledge is grounded at the level of DNA, the genetic code. The genetic code is a blueprint, transcribed within the cell into another molecule, RNA, which provides instructions for the synthesis of proteins. Proteins are the workhorses, performing the manifold functions that allow the cell to thrive by generating energy; they also produce substances that contribute to the body’s growth and development. Each cell joins with others to form a tissue; tissues coalesce into organs; organs form the complete human being. Deep knowledge of each of these anatomic components is the first step toward wisdom of the body. The second step is understanding how the components fit together in health and disease. But while knowledge and understanding are necessary for wisdom, they are not sufficient. What more is needed?

The attribute of discernment must be acquired to reach wisdom. Discernment is the ability to discriminate, to distinguish different levels of knowledge and to apply understanding in a prudent way. Discernment comes largely from experience, learned as we move through life acquiring the ability to weigh what is more or less meaningful in a particular context.

I saw how knowledge, understanding, and discernment compose wisdom when my mother, of blessed memory, was cared for by a team of physicians at Columbia University Medical Center in New York. Her clinical story begins in 1959, when she was thirty years old. At that time, she developed difficulty in seeing out of one eye. We lived in Queens, New York, and medical care was at best uneven. The physician she consulted made a diagnosis of “hysterical blindness”: a young mother with three active children, a hardworking husband, and a part-time job of her own had been pushed over the brink. She was uncertain as to why she had lost vision, but resented the doctor labeling her “hysterical.” His conclusion would prove to be a gross misdiagnosis. My mother’s visual problem spontaneously resolved after several months; its cause seemed to be a mystery.

It turns out that about 15 percent of all complaints are misdiagnosed. Many people assume that such diagnostic mistakes are related to technical factors, like mixing up tubes of blood in the laboratory so that the results given to the physician are for the wrong patient. Such technical errors are, in fact, rare. The vast majority of misdiagnoses are related to cognitive biases, thinking traps that occur more often under time pressure and uncertainty. Many of these biases were identified by the cognitive scientists Daniel Kahneman and Amos Tversky.

Working at the Hebrew University in Jerusalem some three decades ago, Kahneman and Tversky defined a series of thinking errors that helps explain misdiagnosis. The first error is termed “anchoring.” Anchoring occurs when the mind seizes on the first bit of data it encounters and runs with it, rather than considering the full array of potential information. Physicians commonly anchor onto the first symptom or laboratory finding or observation from the physical examination and then quickly draw a conclusion. This conclusion is often correct, but sometimes the doctor has failed to consider that this first bit of information might not provide the key clue to the underlying problem.

A second cognitive error is termed “availability”: we retrieve from memory what is most available, specifically cases recently seen or ones that made a deep impression on us. For example, if we are in the midst of a flu epidemic, then we tend to assume that the patient who comes in with fever, cough, and chills has the flu. The mind is then biased to ignore important findings that contradict this assumption.

A third thinking trap is termed “attribution,” whereby we conform symptoms and clinical findings to fit social or cultural stereotypes in our minds. If an older man comes in unshaven in shabby clothes and tells us that he is retired from the merchant marine and likes to have a glass of rum at night, we will attribute his enlarged liver to alcoholism without stopping to consider that he might have only one glass of rum at night and that there may be a long list of other potential explanations for his liver abnormality beyond alcohol. But the stereotype in our mind tends to bias our thinking and lead us to a premature conclusion.

Wisdom in diagnosis, then, involves not only deep knowledge about human biology and an understanding of the array of diseases that plague humankind but also knowledge and understanding about how the mind works in coming to conclusions. Discerning when these biases are operating in our minds is called metacognition, the ability to think about our thinking. The attribute of humility is embodied in the concept of metacognition; we recognize that our minds are imperfect, that there are limits to the validity of our assumptions, that we are subject to biases, and that therefore we must have the sharp sense to doubt our judgments and question whether we considered everything that should have been considered. Metacognition is essential to clinical wisdom. Why? Because even the minds of the most highly trained doctors are imperfect. These imperfections are amplified when we think under conditions of time pressure and uncertainty, the very conditions of clinical decision-making in today’s medical world. With more patients being seen in ever shorter appointments, physicians are pushed to make rapid judgments, to take shortcuts, and to fall into thinking traps.

The doctor who misdiagnosed my mother did not exercise metacognition. His error in judgment could have been rooted in one or more of the cognitive biases elucidated by Kahneman and Tversky. He may have anchored onto the symptom of blindness in one eye as an isolated abnormality rather than thinking of it in the larger constellation of neurological diseases. He may have fallen into the trap of an availability error, possibly having been particularly impressed by a case of “hysterical blindness” at some point in his career, so he glibly superimposed this prior dramatic experience on my mother’s case. But it is most likely that the doctor made an attribution error, summoning to his mind the stereotype of a frenzied working mother with three children rather than questioning his own biases and thinking more broadly and deeply. Until recently, I was ignorant of these findings from cognitive science; I was not taught the work of Tversky, Kahneman, and others, despite practicing medicine for more than thirty years and having been trained in some of the best institutions in the United States. Modern medicine has successfully drawn from allied fields such as molecular biology, which gives us DNA analysis to understand genetic mutations that cause illness. Modern medicine also has drawn from mechanical engineering, which produces high-performance technologies like CAT scans and MRI scans to greatly assist visualization of tissues and organs in health and disease. And modern medicine has looked to mathematics and computer science to organize vast databases from DNA analysis as well as the images from CAT and MRI scans. But modern medicine has not yet availed itself of the insights from cognitive science, such as how the mind works under conditions of time pressure or uncertainty. I believe that this type of science should be taught to medical students and physicians. We will greatly improve our clinical acumen by learning metacognition, how to think about our thinking in our interactions with our patients and how to improve the soundness of our judgments.

My mother’s blindness spontaneously resolved, but she later developed other symptoms that fortunately led her to wise doctors. One of them, Dr. Linda Lewis at Columbia Neurological Institute, made the correct diagnosis of a degenerative neurological disease akin to multiple sclerosis. Here, a second type of medical wisdom beyond diagnosis was needed: the wisdom to make prudent decisions about treatment. While doctors look to treatment guidelines developed by expert committees about what is termed “best practice,” these guidelines are derived from clinical studies of selected groups of patients, and the “optimal treatment” is based on statistical analysis. Statistics refer to populations, not to individuals, and it is a wise doctor who considers how such guidelines apply to the individual patient sitting before her. Dr. Lewis is guided by an important maxim: “Don’t just do something, stand there.” This may seem counterintuitive in an age when patients expect to leave a doctor’s office with a prescription in hand or a procedure ordered. But in situations that are not emergencies, it is often wise to sit back and observe and think, to better grasp the course of the illness over time in the individual. It is also important to have a clear-eyed view of the risks and benefits of a particular therapy. There are always trade-offs in treatment, the risks of side effects being suffered in the pursuit of improvement in clinical well-being. It is essentially impossible to predict for any individual whether such complications will occur, only to give a probability of side effects and their severity. The treatments for multiple sclerosis are not particularly long-lasting; each affords modest benefit and poses risks of real side effects. Dr. Lewis carefully observed how my mother’s symptoms waxed and waned, how she was able to sustain a reasonable level of functioning, how she continued to live a very high quality of life despite her disease. In the decades that Dr. Lewis cared for my mother, she did not once have to treat her with an aggressive and potentially toxic therapy. Remarkably, the confidence that my mother felt in being cared for with clinical wisdom made her feel better, motivated her to do more, and amplified her sense of good fortune in having a relatively moderate form of illness. Dr. Lewis provided what I think of as the “medicine of friendship,” that special bond between a doctor and a patient when the patient knows that his interests as a sick person are paramount in the doctor’s mind, that the first imperative is to do no harm, and that with deep caring, much can be accomplished.

Wisdom in treatment, then, means not practicing cookbook medicine. One refers to standardized guidelines and then customizes them for the individual patient. Like other forms of clinical wisdom, it requires a deep knowledge of health and disease as well as the formation of an accurate diagnosis and an understanding of the risks and benefits of different treatment options. This means a genuine partnership between doctor and patient, where together the complexity and uncertainty of illness are recognized and accounted for in all decisions.

My mother later developed breast cancer and was cared for by Dr. Gregory Mears at Columbia University Medical Center. He treated her with great wisdom as well. He always informed her of the rationale for a particular therapy and ensured that she felt that the ultimate decision whether to receive a therapy was hers. Thankfully, she entered a prolonged remission. After several years, the cancer returned. At that point, she faced the reality that her condition was incurable. But that did not mean it could not be controlled, with good quality of life. Dr. Mears knew the data from the wealth of clinical trials of different drugs for breast cancer. There were no gaps in his knowledge. He also understood the statistical risks and benefits of each treatment regimen. His wisdom was manifest in discerning which therapies best applied to my mother, and how they might be modified to sustain benefit while reducing side effects in her particular case. Again, an ability to apply guidelines and experimental results to the single patient is the core of clinical sagacity.

There is still one more kind of medical wisdom that, again ironically, I found in a prayer from my tradition. The prayer for healing, in Hebrew, reads: Refuat ha’nefesh refuat ha’guf. Translated, it means “Heal the spirit and heal the body.” Some may think that the sequence of this prayer, which seeks healing for the spirit before healing of the body, might indicate that the mind/spirit must be addressed in order to cure the body. But I believe this is an overly simplistic, “New Age” interpretation. Rather, the prayer acknowledges a unique truth. We all want to heal the body, to treat a specific disease and restore the physical system to health. But the reality of human life is that there comes a time when the healing of the body is impossible. My mother, with Dr. Mears, realized when that time had come. She had written advanced directives, a living will that specified comfort measures rather than intensive and futile treatments. Why, then, did I and all who loved her continue to say this prayer? Yes, we recognized, as she did, that we are all mortal, and so to seek a healing of the body at that last stage of her life was scientifically impossible. But it was still possible to seek a healing of the spirit, the first priority in the prayer. The wise physician and the wise patient both realize that until the last breath, there is the opportunity for the soul to be healed, for conflicts and problems between friends, family, or within the self to be reconciled, so that a sense of peace and harmony is restored. Wisdom in medicine applies to both body and spirit. For each, we draw on knowledge, understanding, and discernment to see what is possible, what can be achieved, and what is meaningful for the person in need.

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