How Orthopaedic Surgeons Think: Lessons Learned from How Doctors Think by Jerome Groopman, MD

A male patient, aged 75 years, had suffered for years with right leg pain. Several MRI studies demonstrated multilevel spinal stenosis. Physical therapy and spinal injections were unsuccessful in alleviating his pain. He subsequently underwent two decompression procedures, with no improvement. Ultimately, the patient sought a second opinion, which noted that his right hip was severely stiffened, and a radiograph confirmed advanced avascular necrosis. A hip replacement ultimately cured his right leg pain.

There are limited data about the frequency of misdiagnosis. Physicians typically begin the diagnosis process from the moment they first shake hands with a patient. They interpret the patient’s appearance, body habitus, and speech even before conducting an examination. Within a few minutes of meeting, physicians often have a mental list of probable diagnoses, often relying on hunches, shortcuts, and rules of thumb. This strategy is known as heuristics. All physicians use heuristics to make decisions about diagnosis and treatment. However, the same tactic that allows us to make quick diagnoses can also lead to errors in treatment. Not every swollen ankle is a sprain, and not every stiff hip is arthritic.

Nearly 20 years ago, author and physician Jerome Groopman, MD, wrote a book titled How Doctors Think, which detailed the decision-making processes used by physicians in patient care. His lessons remain germane today. He described how inconsistencies in information gleaned from the patient history, exam, and diagnostic tools—combined with rapid judgments—were a common problem leading to misdiagnoses in even simple cases. While making team rounds, he discovered that many physicians in the group were not fully attentive or following their patients carefully. The group failed to challenge assumptions about patient care and diagnosis. Dr. Groopman realized that many physicians focused on the most likely possibility using only preliminary data. He learned, by way of reports submitted by physicians, that about 15 percent of all diagnoses were incorrect. Dr. Groopman relates that the frequency and seriousness of diagnostic and treatment errors can be reduced by “understanding how a doctor thinks and how he or she can think better.”

Effective decision making may be the most important skill that an orthopaedic surgeon possesses. Many orthopaedic complaints have a range of diagnostic and therapeutic possibilities. Grey areas are common. For example, differentiating whether hip pain is generated from a degenerative spine or an arthritic hip can lead to diagnostic and therapeutic errors. Although tools such as artificial intelligence may assist in improving diagnostic accuracy, ultimately the physician must make the final decision for diagnosis and treatment.

All physicians have biases based on their experiences, training, and comfort level in interacting with patients. Age, body habitus, and ethnic or racial stereotypes can all influence the diagnostic process. Patients with more complex conditions may experience delayed diagnosis or treatment, as many physicians are not as enthusiastic about working on complicated cases. A patient may be viewed as a series of systems and not recognized as a whole person—leading the physician to miss the bigger picture and overlook a systemic condition. Although intellectual mistakes do occur, Dr. Groopman reminds readers to try to avoid biases and stereotypes that can lead to incorrect conclusions.

Misdiagnosis can also result from the use of a heuristic technique known as “availability bias,” which is the tendency to judge the likelihood of a diagnosis based on the ease to which this diagnosis comes to mind. Time is limited when seeing patients. The most expedient route may be to focus on the first and most likely diagnostic possibility. In his observations, Dr. Groopman realized that many physicians arrived at a likely diagnosis within minutes of meeting a patient.

In his book, Dr. Groopman described a series of events leading to “diagnosis momentum,” when a physician makes a diagnosis, correct or incorrect, that is passed on to other treating physicians. Consider the following example: A patient developed pain and an effusion months after a knee arthroplasty performed for rheumatoid arthritis. An elevated sedimentation rate, C-reactive protein, and serum white blood cell count led to a diagnosis of a septic knee. Revision surgery was performed and the patient was prescribed a 6-week course of antibiotics. However, her symptoms persisted. Ultimately, she was started again on biologics, and her swelling and pain rapidly resolved. Her incorrect diagnosis had been passed across a range of specialists who cared for her during her several months of unnecessary treatment.

To stop diagnosis momentum in its tracks, Dr. Groopman developed a series of questions and steps for patients and their physicians to elucidate other potential diagnoses:

1. What else could it be?
2. Is there anything that doesn’t fit?
3. Is it possible that there is more than one problem?
4. Make sure the patient expresses what they are most worried about.
5. Retell the story from the beginning.

Dr. Groopman’s advice to patients and physicians is to ask open-ended questions. Patients should be encouraged to participate in their own diagnosis and treatment. Better dialogue requires physicians to be better listeners. In addition, physicians should be cautious to describe the whole range of treatment possibilities, likely outcomes, and alternative choices. Second opinions should be encouraged. Repeat tests in case of inconsistencies. Physicians and their patients should be partners to promote optimization of care and medical decision making.

Thomas Fleeter, MD, MBA, FAAOS, is in private practice in Reston, Virginia, with Town Center Orthopaedics. He is the chair of the AAOS Committee on Professionalism and former member of the AAOS Now Editorial Board.