Free How Doctors Think by Jerome Groopman Page B

pressure. The changes in circulation may mimic menopausal hot flashes and precipitate severe migraine-like headaches. The catecholamines can also cause psychological symptoms such as anxiety, despair, and even aggression. If untreated, the patient may have a stroke or heart or kidney failure.
    "She had surgery and the tumor was removed. Now her hot flashes are much less severe, as are her headaches, at the level you would expect during menopause," Delgado said. "But Ellen is still kooky, by her own admission."
    Delgado believes that patients or family members can adopt Ellen Barnett's approach. With a disarming sense of humor, she communicated that she understood she fit a certain social stereotype, and that stereotype had caused her doctors to fail to fully consider her complaints. "I didn't feel like Ellen was being obnoxious or patronizing," Delgado said, "and I didn't react and become alienated or annoyed with her. What she said enhanced her credibility and helped me avoid an attribution error."
    Negative feelings that patients like Ellen Barnett trigger in a physician are usually close to the surface. But positive feelings, like the ones Croskerry had for Evan McKinley, Falchuk had for Joe Stern, and I had for Brad Miller, are more difficult to recognize as dangerous. Since Delgado is a physician who has genuine affection for many of her patients, I asked whether she had ever fallen into that trap, the trap of affective error. She thought she had. "I had an elderly patient with thyroid cancer and considered treating him with radioactive iodine. There are difficult logistics involved with the therapy, and it really can disrupt the person's life. I was just about to refrain from treating this man when he said to me: 'Don't save me from an unpleasant test just because we're friends.'" At best, in severe circumstances, the family or friends of patients who realize that a doctor's affection may stay his hand at times can address this concern by saying: "You should know how deeply we appreciate how much care you show. Please know also that we understand you may need to do things that cause discomfort or pain."
    Only a layman aware of how such feelings can color a doctor's judgment in subtle but significant ways could make such a remark. In pondering Delgado's vignette, I realized it would have been impossible for Brad Miller to muster the energy to think about our prior interactions and warn me this way when I saw him that morning on rounds. It was my job to be complete in my exam, and my charge to monitor my feelings when they might break my discipline.
    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.

Chapter 3
    Spinning Plates
    T UBA CITY, ARIZONA, lies 3,246 miles west of Halifax, Nova Scotia. Halifax was the first British town in Canada, founded in 1749; most of its 360,000 inhabitants still trace their roots to the British Isles. Tuba City has a population of just 6,000, but it serves as the central town for more than 100,000 members of the Navajo and Hopi nations. Modern glass-and-steel skyscrapers ring the Halifax harbor, and a sharp northern light reflects off the sea. Tuba City sits on high mesa, the surrounding country highlighted by scrub and the soft pastels of ancient sedimentary rock. Halifax's Dalhousie University Medical School is renowned for its academic departments and cadres of researchers. The hospital in Tuba City is a cluster of low-slung dun-colored buildings housing the Indian Health Service; the nearest MRI scanner is an hour's drive away. Despite these differences in geography, size, resources, and culture, an emergency room physician in Tuba City, like Dr. Harrison Alter, has to recognize the same clinical patterns and avoid the same cognitive errors as a counterpart in Halifax like Pat Croskerry.
    Alter, who is forty-three, did not initially see himself as a