Week 12: Flesh-and Blood Decision-Making Jerome Groopman Dr. Peih-ying Lu May. 13, 2010

 According to Groopman, in 1980s, what were interns like? What did they have to do?  How did the first day of intern influence Dr. Groopman? How has his feeling changed?  In medical school, how do students study paper cases? Pre-reading questions

 How long will it take in a didactic exercise for the senior doctor and students to arrive at a working diagnosis?  How long will it take an expert clinician to form the notion of what is wrong with the patient? Pre-reading questions

 According to Dr. Pat Croskerry, what is pattern recognition?  According to Dr. Donald A. Schön, what is heuristics?  What is the Yerkes-Dodson law? How does it relate to doctors’ performance?

Pre-reading questions  What is the function of the high-tech mannequin named Stan?

Case 1: William Morgan Groopman's first day of intern Morgan: 66, African-American, hypertension No abnormality in his esophagus or stomach Emergency Morgan’s eyes widen, jaw fell stack, and chest heaved violently. Dr. John Burnside said he tore through his aortic valve. Groopman’s frustration Morgan had a cardiac surgery. In the real world, Groopman gave himself an F.

Case 2: Anne Dodge Dodge: 22, having seen 30 physicians in 15 years. Her family doctor found nothing wrong. A psychiatrist said she had anorexia nervosa with bulimia. Dodge’s internist said she had Irritable Bowel Syndrome (IBS), and should consume 3000 calories a day. By 2004, Dodge weighted only 82 pounds, and her internist and her psychiatrist took the loss of the weight as her NOT telling the truth. Giving treatment outside the statistically proven, Dr. Myron Falchuk questioned, listened, observed, and thought differently about Dodge’s case.

In case 1, Dr. John Burnside spent only 15 seconds finding out what was wrong with Morgan while others spent 15 years figuring out Dodge’s illness in case 2. What’s the difference?

Patterns Recognitions From the medical history, physical examination, x-ray studies, or laboratory tests – coalesce into a pattern that the physician identifies as a specific disease or condition. Pattern recognition reflects an immediacy of perception. It occurs within seconds, largely without any conscious analysis; it draws most heavily on the doctor’s visual appraisal of the patient. And it does not occur by a linear, step-by-step combining of cues. The mind acts like a magnet, pulling in the cues from all directions.

Inner Feelings Most people assume that medical decision- making is an objective and rational process, free from the intrusion of emotion. Yet …. the opposite is true.

In-Class Discussion  What are Dr. Groopman’s inner feelings towards both Anne Dodge’s and Mr. Morgan’s cases?  What do you think the differences and similarities are between these two cases?  Do you think doctors’ medical decisions are made subjectively or objectively? Why?  What is “see one” and “do one”?

In-Class Discussion  Is a fast and frugal medical decision always better than a nice and slow one? Why or why not?  Do you think the technical errors in medicine, which are like prescribing the wrong dose of a drug, transfusing a unit of blood matched for another person, mislabeling an x-ray of an arm as “right” instead of “left”, are inevitable?

In-Class Discussion When are intuition (in The Blink), pattern recognition by Dr. Pat Croskerry, and heuristics by Dr. Donald A. Schön being used? How should doctors avoid mistakes when using intuition? Why?

Christine Borland said, “I’ve tried to speak to young doctors and talked to them about their real experiences, for example, of breaking bad news, and how they compare their experiences as students and whether they’re drawing on these experiences with actors. Once they get out there into the real medical world and they are looking back at their education, what do they think about it?

However, going by their descriptions, of the difficulties of breaking bad news, for example, in a real situation compared with the learning situation, a lot of them were questioning the use of simulated patients.” (Lu, 2010: 96)

Lu, P.-y. (2010). Medical communication as art – an interview with Christine Borland. Language and Intercultural Communication. Vol.10, No.1, )