Letter From the Editor

Bruce D. Cheson, MD

Clinical Advances in Hematology and Oncology
December 2012, Volume 10, Issue 12

The pinot was from Santa Barbara, and quite nice, the Torrontés was crisp with just a hint of fruit. The cheese and crudités completed the menu. In this setting we had our fellows’ and faculty’s Book Club last evening. This time I selected the “New York Times Bestseller” (as headlined on the cover) How Doctors Think, by an old colleague, Jerry Groopman. It is intended to enlighten physicians as to types of errors that they can avoid, and to enable patients to improve the interaction with their physician so as to receive the best care possible.

I must say that the discussion was more spirited than I had predicted, and brought out many feelings from the fellows and staff that, whilst sometimes tangential to the book itself, were revealing of their concerns. Jerry discusses a series of dangers that can lead to misdiagnoses and medical errors. We all related to the situation where a patient has been labeled with either a diagnosis or a personality disorder long before they are referred, and the difficulties in getting past those preconceptions. How do you ensure that you don’t get so locked in? The elders in the room recalled the day when you were required to develop a differential diagnosis list and to go through all the possibilities until the correct one was identified. We bemoaned the practice of having sets of studies for a particular diagnosis, rather than having to think about why precisely you were ordering a particular test. Patients get trapped in the clinical algorithm which, when followed blindly, leads to an increase in care costs, and no increase in diagnostic acumen.

One question we debated was whether raised awareness was sufficient to avoid the pitfalls, the greatest of which was poor communication. For example, a doctor generally interrupts a patient within 23 seconds of initiating a conversation. We are told that our education has been deficient in interpersonal interactions and the mental steps of decision making. But, are we all educable? The consensus was basically that some have the ability and others never will.

Many of the errors we attributed to time. In private practice, where volume is essential, mistakes may occur because there is a lack of opportunity to ponder and to bounce ideas off colleagues, or epiphanies that often occur (at least to me) when discussing a case with the fellows. The sense was that the academic setting provides more opportunity for interactive thought. On the other hand, patients often drive for hours to see us, whereas their local oncologist has the luxury of being able to bring them back the next week to review the case once again.

But, it was emotional involvement with patients and the consequences thereof that occupied the largest block of time. Is it appropriate to cry in front of a patient, one fellow asked? I wasn’t allowed to respond until she completed an anecdote: she had cried during a patient visit, and apologized. The patient responded to the apology with a hug, and stated that it made her feel better to know that her doctor cared enough to cry. But, how much involvement is too much, where do you draw the line? No answers were readily available except that you have probably gone too far when the patient starts to feel sorry for the doctor! How those feelings impact on care generated a good discussion, starting with the description of a patient who was very well liked and wanted to be discharged to go trick-or-treating with her daughter, probably for the last time. When the fellow presented her situation to the attending, she was told, “If it was Mrs. X,” (whom no one cared much for) “instead, would you let her go?” The fellow responded, “Absolutely not!” Thus said, the beloved patient remained in the hospital, where she decompensated during the night and ended up in intensive care. Had she been discharged, it would have been a most unpleasant evening.

The group did feel that there were misconceptions and missed opportunities within the book, such as a suggestion that more is better testing-wise and therapeutically. In addition, there was a failure to mention the value of clinical trials.

I am glad that I chose this book. It was a worthwhile read and stimulated a memorable Book Club. Such afternoons also afford me the privilege of getting to know my fellows and colleagues better.

Until next month . . .

Bruce D. Cheson, MD