January 7, 2008
I read a thought-provoking new book over the Christmas Break: How Doctors Think, by Jerome Groopman. The implications of this book reach much further than that title suggests. A more descriptive title might have been “How To Reduce the Likelihood that You Will Make A Big Mistake” or “Here’s Some Help in Knowing What You Don’t Know.” For this book is really about how our cognitive processes, and our feelings, can lead us to draw incorrect conclusions from data — in short, to make errors in judgment. This book analyzes that problem through the lens of clinicians making diagnoses in hospitals and doctors’ offices, but it could just as well have adopted a different lens and studied how certain cognitive processes lead CEOs — or, for that matter, college presidents — to draw incorrect conclusions and then use them to make bad decisions. If the book had adopted one of these different lenses it would obviously have created a different context for discussing its subject, but it still would have been about the same thing.
In his book, Groopman makes extensive use of the research done by cognitive psychologists who study the processes by which we come to “know” things. These psychologists have identified and named many of the common cognitive processes that can lead us into error. For example, there is the “availability error,” which is “the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind” (p. 64). Groopman uses the example of a doctor who misdiagnosed aspirin toxicity in a woman because she came into his office presenting many of the symptoms of subclinical pneumonia, and this woman lived on a reservation where the doctor had seen numerous pneumonia cases in other patients from that same reservation recently. Or there’s a related process called “anchoring”: “a shortcut in thinking where a person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one” (p. 65). Another cognitive process that can lead to error, and one which is frequently a consequence of anchoring, is “confirmation bias,” which means “selectively accepting or ignoring information” (p. 65). If you latch too early on to a diagnosis (that’s anchoring), then you are likely to pay attention to the symptoms that confirm that diagnosis and to ignore those that, inconveniently, do not (that’s confirmation bias). You end up with a wrong conclusion because you have unconsciously only attended to evidence that confirms a belief you have already formed.
There are many examples like this in the book. Not all of them illustrate cognitive errors, by the way. Some are “affective errors,” in which we are led astray by our emotions rather than by our cognitive processes. Groopman tells a story about a doctor who sympathized so much with a patient’s suffering that at a crucial point in the path to a diagnosis he decides not to order an invasive test that, if it had been ordered, would have identified the patient’s disease. As Groopman says in a particularly eloquent passage, “Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents” (p. 58).
I am often asked, “What keeps you up at night?” The truth is that most nights I sleep soundly, but if you were to pass the president’s house in the wee hours of the morning and see the lights on in my study, it’s not because I’m up watching re-runs of “Seinfeld.” I’m worrying about what I don’t know that I don’t know. Am I unconsciously committing the kinds of cognitive or affective errors Groopman describes in his book? What evidence might I be unconsciously ignoring as I think about the college and its future and try to bring the St. Olaf family together around the vision that is best for our college? Have I come too swiftly to a belief about St. Olaf because it fit neatly into my most recent experiences or into my expectations about what was likely to happen? How could I avoid such mistakes?
This book teaches humility. It reminds you not only how much you don’t know but also how hard it is to know when you don’t know something. It teaches you that you might be led astray by your mind or your heart — or both — when you are trying to think clearly about data. It doesn’t counsel despair, and it certainly doesn’t argue that we should give up trying to think analytically because sometimes we make mistakes, but like Greek tragedy and the Book of Job, it reminds us forcefully of our limitations.
Why am I talking about this in chapel, and what does How Doctors Think have to do with the 12th chapter of Romans? Because the text for today is also about humility, in this case Christian humility. Paul writes: “For by the grace given to me, I say to everyone among you not to think of yourself more highly than you ought to think, but to think with sober judgment, each according to the measure of faith that God has assigned” (12:3). This blunt caution against the sin of pride doesn’t come out the blue. In this section of the epistle to the Romans, Paul is laying down principles for life in Christian community. The first principle — the “essential preliminary” as one commentary has it (The Interpreter’s Bible, 1954, IX, 583) — is to practice humility. Paul recognizes that the different members of the community have different gifts, passions, interests, and he assumes that those gifts and passions each, in their own way, have the potential to contribute to the life of the community — “We have gifts that differ according to the grace given to us: prophecy, in proportion to faith; ministry, in ministering; the teacher, in teaching; the exhorter, in exhorting; the giver, in generosity; the leader, in diligence; the compassionate, in cheerfulness” (12:6-8). But, crucially for Paul, these gifts have to be understood not as gifts that belong to us — indeed, they are manifestations of God’s grace — but rather they must be seen within the context of the life of the whole. Paul admonishes us to know ourselves well enough to subordinate our gifts and ourselves to the good of the community as a whole, for “we, who are many, are one body in Christ, and individually we are members one of another” (12:5).
How, then, can each of us know what our particular gifts are, and how can we know when and where to employ the gifts we have been given in service of the life of the community? According to Paul, it all begins with looking at ourselves with “sober judgment.” Now, that doesn’t sound like much fun, and indeed I don’t believe Paul wants us to get up every morning, look in the mirror, enumerate our faults, failings, and inadequacies, and then sally forth to live as Christians armed with this fresh audit of our limitations. But I do think he would have us bring to our life in community a healthy awareness of the limitations of human knowledge in general and the limits of our individual powers of reasoning and knowledge. This awareness of our limitations is healthy because it prevents us from leaping to readily available conclusions, privileging the data that confirm those conclusions and ignoring the data that don’t, and becoming over-confident in our powers of discernment.
This admonition from Paul is challenging to all Christians, but it is particularly challenging to Christians at a college because, of course, college is where you go to develop your base of knowledge, strengthen your powers of reason, and hone your ability to argue your point of view. College is where we encounter the breadth and range of human knowledge and explore the power of the intellect. As far as I’m aware, we don’t have many courses at St. Olaf with names like “Here are All the Things We Don’t Know,” or “Cognitive Habits that are Likely to Get You in Big Trouble.” Can How Doctors Think help us exercise “sober judgment” about ourselves so that we can employ our particular gifts and talents in service of that lofty goal?
I think so. Here are some of the tools that the doctors described in this book use to help them avoid the many kinds of errors this book documents.
Ask open-ended questions. The first story in the book concerns the doctor of last resort for a patient who had been misdiagnosed by a long range of specialists, each of whom accepted, and built upon, her internist’s initial diagnosis. It was incorrect, and, as a result, the therapy recommended merely aggravated the patient’s symptoms and increased her suffering. The doctor of last resort pushed aside her medical records, took out a blank sheet of paper, and asked her to describe, in her own words, when she began to get sick and how she felt. This was what it took to get outside the closed loop of assumptions that led to a misdiagnosis and a dangerous therapy that brought her near death.
Be aware of how your own emotions and reactions might be affecting your thinking. Groopman writes honestly about how patients thought to have a psychological disorder tend not to be believed by doctors who are diagnosing a physical malady and how that can affect their medical care, about the distaste some doctors feel for certain indigent patients, and about a physician’s need to preserve emotional distance from patients for whom, out of affection or pity, they might be tempted not to order an unpleasant and invasive test.
Embrace uncertainty. Groopman spends a chapter on a pediatric cardiologist who tries to focus on the piece of data that doesn’t fit. Studies show that over-confident people tend to focus on positive rather than negative data, and this physician tries to avoid “confirmation bias” by seeking the data that fail to confirm a diagnosis. Groopman quotes a scholar at MIT who has studied how professionals think that expresses this strategy:
Because of some puzzling, troubling, interesting phenomena, a physician
expresses uncertainty, takes the time to reflect, and allows himself to be
vulnerable. Then he restructures the problem. This is the key to the art
of dealing with situations of uncertainty, instability, uniqueness, and value
Measure and assess. Groopman’s chapter on radiologists is rich with techniques that physicians in this specialty use to understand the kinds of errors most frequently made when reading an x-ray, and almost all of them are based upon systematic, quantitative study of outcomes, the results of which are then fed back into the daily practices of radiologists to reduce error and to improve patient care.
None of these tools is unheard of. In fact, they are well-known. You might say they amount to nothing more than common sense. What makes this book so helpful to read, and so pertinent to our own need to see ourselves with “sober judgment,” is the cast of mind that lies behind it. This cast of mind recognizes how often we are wrong. It looks honestly at the limits of both our knowledge and our ways of knowing, and it acknowledges the power of our emotions to affect our decision-making. But it’s a remarkably optimistic book. It’s full of stories about correct diagnoses, about cures, about decision-makers learning to know themselves better and to do better work.
Each of us is, in our lives at St. Olaf and in our lives as Christians, similarly, a decision-maker every time we come to a conclusion, embrace a belief, assert an argument, declare ourselves in one way or another. And we should be decision-makers in this way, for people look to this college and its people for leadership across a broad range of human activities. We cannot and we should not shirk this responsibility. My hope is that we embrace it in the spirit of “How Doctors Think” and in the spirit of Paul’s admonition to the early Roman church: to see ourselves with sober judgment, to envision ourselves as giving our gifts to the community of the faithful to serve the common good. In this way we employ our gifts to God’s glory, we nurture and sustain our life together, and we do good work.
David R. Anderson ’74