Fine-tuning the thought process (book excerpt: How Doctors Think)

Massachusetts hematologist-oncologist Jerome Groopman, MD, examines how doctors arrive at clinical decisions.

By Jerome Groopman, MD, AMNews contributor. Oct. 8, 2007.

Book Excerpt
A peek inside what's new on the shelves on topics pertinent to physicians.

Dr. Groopman's book details why physicians' thinking can lead them astray and shows how to make the correct diagnosis. This excerpt explores the thought process of an emergency physician who missed a heart problem in a patient who appeared healthy.

On a spring afternoon several years ago, Evan McKinley was hiking in the woods near Halifax, Nova Scotia, when a pain in his chest stopped him in his tracks. McKinley was a [Canadian] forest ranger in his early 40s, trim and extremely fit, with straw-blond hair and chiseled features. He had had a growing discomfort in his chest for the past few days, but nothing as severe as this. He wasn't sweating or lightheaded, and didn't feel feverish. But each time he took a breath, the pain got worse. McKinley slowly made his way back through the woods to the shed that housed his office. He sat and waited for the pain to pass, but it didn't. As a forest ranger, he was used to muscle aches from scaling a steep rocky trail or jogging with a loaded pack on his back. But this was different, and he decided he should see a doctor immediately.

As it happened, Dr. Pat Croskerry was working in the emergency department that day. He took McKinley's measure: a wiry, muscular man wearing the distinctive bright olive bomber jacket and pants, much like an American park ranger's uniform. McKinley's face was ruddy, as would be expected of someone who spends most of his day working outdoors, and his brow was free of perspiration. Croskerry listened intently as McKinley described how his chest pains had increased over the past few days and how they had worsened today. Croskerry questioned him further to get a more precise description of his symptoms. McKinley said the pains stayed in the center of his chest but did not move down his arms, into his neck, or through to his back. The pain got no worse if he changed position, and even taking a really deep breath didn't make him feel faint.