Free How Doctors Think by Jerome Groopman Page A

the morning and returned to the streets. Some hours later, she felt a nurse tugging at her sleeve. "I really want you to go back and examine that guy," the nurse said. Delgado was reluctant, but she had learned to respect an ER nurse who felt that something was really wrong with a patient.
    "His blood sugar was sky-high," Delgado told me. The young man was on the brink of a diabetic coma. He had fallen asleep near the art museum because he was weak and lethargic and unable to make it back to his apartment. It turned out that he was not a vagrant but a student, and his difficulties giving the police and the triage nurse information reflected the metabolic changes that typify out-of-control diabetes.
    "The hardest thing about being a doctor," Delgado said, "is that you learn best from your mistakes, mistakes made on living people." Chastened by the experience, she conjured up the picture of that young man whenever she was called to the ER to evaluate other disheveled and uncooperative people. But, Delgado continued, that was a single experience corresponding to a single stereotype. "It is impossible to catalog all of the stereotypes that you carry in your mind," she said, "or to consistently recognize that you are fitting the individual before you into a stereotypical mold. But you don't want to have to make a mistake to learn with each stereotype." Rather, Delgado believes, patients and their families should be aware that a doctor relies on pattern recognition in his work and, understandably, draws on stereotypes to make decisions. With that knowledge, they can help him avoid attribution errors.
    Is this really possible? I asked.
    "Sure, it's not easy for laypeople to do," Delgado said, "because patients and their families are especially reluctant to question a doctor's thinking when their questioning suggests his thinking is colored by personal prejudice or bias." Still, Delgado thinks lay-people can diplomatically direct a doctor's attention to his reliance on stereotypes, because one of her patients had done this with her.
    Ellen Barnett had recently sought out Dr. Delgado for help with a multitude of vexing symptoms. Many people who see Delgado have symptoms that are difficult to pin down—low energy, for example, or abrupt weight gain—and assume they have a hormonal or metabolic imbalance. Usually they don't. Ellen Barnett had already consulted five physicians and felt all five had shunned her. "I'm having what I call explosions, feeling hot all over, which make my skin crawl. I mean really crawl, like ants all over, and sometimes they come with terrible headaches," she told Delgado. "Really, it's like a bomb going off in my body. I know I am in menopause, and all five doctors told me that that's the cause of my problems. And two told me that I'm crazy. And, frankly, I am a little crazy," Barnett said with a wry smile. "Okay, I know menopausal women have hot flashes. But I think this is something else, that what I'm feeling is more than just menopause."
    As Delgado listened, she recognized how easy it would be to make an attribution error with a persistently complaining, melodramatic menopausal woman who quite accurately describes herself as kooky. So she stopped herself from casting Ellen Barnett as a stereotype and assumed for a minute that her patient was telling her something important, something meaningful, that these "explosions" were indeed different from run-of-the-mill menopausal hot flashes and hormonal migraines.
    "I evaluated her very extensively," Delgado said, "and it turned out that, yes, she was menopausal, and yes, she was a strange person with lots of weird ideas, but what turned up in her urine was not from menopause or being kooky. Her catecholamine levels were through the roof. A CT scan showed a pheochromocytoma above her left kidney." A pheochromocytoma is a relatively rare endocrine tumor that produces catecholamines, chemicals like adrenaline that can cause wild swings in blood flow and blood