How Doctors Think

Doctors 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 that deals with the subject has hit the best-seller list.

There are some parts of the brain that a doctor uses preferentially over others, memory being perhaps one of 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!

In the next phase as they progress to 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 picks up through experience, a feature called “probabilistic” thinking. To take the example of chest pain for instance, he starts recognizing that the same symptom in a young 20-year-old woman is almost always of neuro-muscular origin, and hardly ever from the heart. On the other hand, if the patient is a 50-year-old overweight smoker with high BP, it is very likely to be a heart attack, and calls for 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-year-old schoolgirl with recent onset vomiting require an endoscopic examination right away? What if her mother tells you that 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, spiced with a sensitive understanding of his patient’s concerns and constraints that make him take decisions that posterity seems to approve. 

A wine matured over decades may have the same content of alcohol as a recently fermented one, but the discerning taster can easily spot the difference.

Knowledge alone does not make a good doctor; the flavor also counts!

As published in HT City ( Hindustan Times) dated 9th December, 2012.