A physician examines his profession’s blind spots

Jerome Groopman is a physician and clinical scientist at Harvard University, a specialist in AIDS and cancer. He’s also a writer for The New Yorker, with a successful and thought-provoking series of books on such topics as the intersection of spirituality and medicine and the importance of a physician’s intuition. His new book, “How Doctors Think,” asks the question: Why do doctors make mistakes and how can we keep them from happening?

Zachary Sholem Berger: How can patient and doctor better understand each other?

Jerome Groopman: Language is still the bedrock of medicine, despite all the great technology we have. I have a great doctor who listens very carefully, lets me tell my story; sometimes he interrupts to guide me. He is an active listener, explaining how he understood what I said and then explaining his thinking to me.

I’ve tried to make myself a better doctor. Like most medical students, I was not educated in thinking about thinking. At least I’ve become much more self-aware. Hopefully through the process of writing this book, I’ll think better for my patients.

ZSB: How can a doctor retrain himself or herself in order to listen more, be open to more diagnostic possibilities?

JG: By and large, we do a good job as doctors. We’re right about 80 percent of the time — our misdiagnosis rate is 15 percent to 20 percent, which is remarkable. But in about half of misdiagnoses, there is serious harm to the patient. My hope is that people in charge of medical education will seriously look at this and ask how can we do better in terms of educating doctors to think about their thinking and avoiding pitfalls.

This concern comes out of the experience of the patient. Because we doctors see so many people, thinking in the moment, we have to use shortcuts. If lay people become educated about how we think, with a few appropriate and directed questions, they could help us think better.

They should ask, “Could this be anything else?” or “I’m worried this is something serious.”

That is the genuine partnership.

ZSB: Could it be that the issue is not only thinking, but that doctor and patient need to understand how the other feels?

JG: There’s an integration of thinking and feeling; our emotions color our thought processes. In the real world, pitfalls in thinking are also influenced by our emotions. So you have to recognize feelings — to be self-aware and know there are going to be patients that you adore. That can impair your judgment, as well. The flip side is there are patients we don’t like, that we find irritating or provocative.

ZSB: Do patients have to recognize feelings, as well?

JG: It’s much harder to be a patient than a doctor. Research I mention in the book shows that patients pick up accurately if doctors like them or don’t like them. Patients need to defuse such a situation or open it up. There are patients who have said to me, “I can feel how devoted you are to me. I don’t want you to hold back.” If [on the other hand] you feel like the doctor’s irritating you, as I experienced myself as a patient, that’s a red flag.

ZSB: What does the Jewish tradition mean to you?

JG: I feel its importance very deeply. There is room in it for doubt and skepticism and questioning, not a sense of infallibility. There’s also extraordinary psychological insight with regard to motivation and character. For example, Maimonides talks about magical thinking, and the Torah talks about not believing in sorcery — often patients do have magical thinking, believing that they will be saved.

ZSB: Doctors, too — magical thinking guards us against admitting our ignorance.

JG: That’s right! So we should be challenging ourselves. Judaism impels you to challenge yourself. In the greatest debates in Talmud, you are able to challenge the greatest authorities.

ZSB: Do you feel recourse to spirituality, to God?

JG: As much as I wish there were miracles — boom, my hand’s fixed — those are fantasies. What Judaism teaches us is the knowledge that we’re created with reservoirs of resilience. We are created with the capacity of wisdom, which means judgment — not just knowledge, but the ability to assess and weigh that knowledge to make choices. Very integral in Judaism is the sense of hope. There is capacity to improve. What it takes is drawing on gifts of science with mobilization of the spirit.

ZSB: How do you mobilize the patient’s spirit?

JG: I try to draw from them wellsprings of their resilience, to lift them up as best I can. The diseases I deal with are serious ones. The confrontation with those kinds of realities requires energy and commitment and determination on the part of a patient.

ZSB: Is the spirituality you’ve talked about just a fancy name for trying to inject religion?

JG: I don’t think you need to be religious to have a sense of awe or to look within yourself or around you for nonreligious sources of strength, whether they be family, friends or therapists. I care for many people who are atheist and agnostic, and I certainly don’t have the hubris of imposing any religious sensibility on them. My job as a physician is to help them find that core of strength and focus.

Zackary Sholem Berger, a frequent Forward contributor, is a medical resident in the primary care program at New York University.

Déja Date

They say that familiarity breeds contempt, but I’m thinking that when you meet so many strangers in so short a time, familiarity might just breed comfort. You see a guy’s picture 20 times, you begin to feel you know him. Maybe the first time he wrote to you, you weren’t sure about him — maybe he even creeped you out — but a year or two later he practically seems like family (possibly that family member you want to avoid, but family nonetheless).

Maybe that’s why when Eric writes me, his picture appeals to me. He reminds me of someone. Someone … someone like … him!

It takes us a bit before he realizes that we’ve gone out before. It was two years ago — that’s 10 years in dating time — and we actually went out twice. (I guess I wasn’t the one-hit-dating wonder then that I am now.)

Eric wants to know now if I’d like to go out again. Now, two years later. I’m not sure. I can’t recall much about Eric. But maybe that’s because I don’t possess the best memory in the world. OK, my memory is about as good as a stoned amnesiac’s. There are entire years of my life I’ve blocked from my mind, shredded like crucial government documents.

I do remember, though, where we had dinner on the second date. (I’m drawing a complete blank on the first, though. Actually I sincerely doubt we had two dates, but I have to take his word for it — I always have to take other people’s words for the past). I remember that he kissed me. I remember he had a cat. And I know that I was allergic to cats then and still am.

But here’s what I don’t remember: I don’t remember what else was going on in my life at the time; I don’t remember why exactly I didn’t like him, and I don’t remember how exactly it ended.

So here’s the real question. Is timing everything? Is context anything?

Are we malleable, whimsical creatures whose predilections are determined only by the season, our moods, the placement of the moon in the sky?

Or is there a solid core inside, a hard drive of basic preferences and tastes that consistently governs the choices that we make? Are our instincts infallible?

I am someone who goes by instinct. Like most people, I like to think that I have good instincts. On the other hand, my relationship track record might suggest otherwise. My instincts, I suppose, have not always been right.

So in the name of being less picky, I decide to go out with Eric again.

There is a comfort level to our phone conversations that I usually don’t have with strangers. I suppose it’s because he’s not exactly a stranger. He knows things about me that I don’t know how he knows except that I must have told him. He knows that I surf, he knows that I’m allergic to cats (“still?”) and that he really liked me the last time, but I just wasn’t interested.

I’m hoping that when I see Eric, it will all come back to me. That I’d be like one of those characters in a miniseries who is jolted into recovery by the sight of her loved one.

No such luck. When I see Eric, I see why I didn’t recognize his picture in the first place — he doesn’t look like his picture. He does look like someone I might have gone out with already, but then again, maybe not.

I’m checking my instincts, taking my emotional temperature and getting nothing. “No pulse, doctor.” Not a blip on the EKG. Flat-lining.

So I do what I always do in these memory-failure situations. I decide to start from scratch with Eric, find out about him. It goes well, apparently, because he asks me out again. I can’t find a reason to say no — not a good reason, not if I am going by something other than mere instinct.

But what else is there? We live by our gut, our instincts, our heart, whatever you want to call it. Perhaps intuition can be warped, perhaps it needs to be refined, therapized, cauterized, redirected, reshaped — but should we ignore it? To ignore it is to go out on a second — actually fourth — date with a man you don’t like. You don’t know why you don’t like him, you can’t put your finger on it, but you also know you don’t have to put your finger on it.

You can, in the end, just act like a brat and get into some stupid spat with this man you’ll never see again, simply because you’re there in this situation despite your own good judgment.

So I slam down some money, walk out and screech out of the parking lot like a getaway driver, and then I realize that I didn’t remember Eric for a good reason: He wasn’t memorable.

This time I’ll remember him — I hope — or at least I’ll remember this: My intuition may not be good, but for now, it’s the best thing I’ve got.