In an increasingly pressured and technological medical world, Dr. Jerome
Groopman makes a practice of tuning out the noise. He listens instead to a still, small voice: his own intuition and that of his patients.
A cancer and blood specialist, Groopman holds an endowed professorship at Harvard Medical School and is chief of experimental medicine at a Harvard teaching hospital. His laboratory helped develop drugs that revolutionized the treatment of HIV and identified two genes linked to breast cancer.
He is, in other words, the epitome of an academic research scientist. Yet Groopman believes that good medicine makes room for the unquantifiable input of gut instinct and emotion from both doctors and patients.
The encounters that result are captured in his new book, "Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine" (Viking, $24.95). In its narratives, Groopman describes patients he has treated: a wealthy man whose local doctors fear that if he consults a specialist, their hospital will lose his patronage; a cleaning woman whose cancer is misdiagnosed by an overworked clinic doctor; a mother trying to decide between risking breast cancer, which runs in her family, and having her breasts removed. Interspersed with these accounts are moments from Groopman's own experience: as a family member when his grandfather, father and son were caught in medical crises, and as a bullheaded back-pain patient ignoring his own doctors' advice.
A thread of argument links the chapters: Groopman's conviction that the patient's perspective and the physician's instincts are as important to medical decision-making as clinical guidelines and research results.
Recently, Groopman spoke with the Journal-Constitution about encouraging patients --- and doctors --- to trust their intuition and speak up.
Q: It seems odd to hear a research scientist recommend listening to intuition.
A: Medicine is certainly a science --- but it's not an exact science. There is a dimension to medicine that involves the intersection of information, observation, experience and instinct. Some of it involves knowing the person whom you're caring for, understanding their personality and their body language.
When you struggle with a diagnosis or treatment, those elements --- which are not quantifiable --- have real importance in guiding your thinking.
Q: Can you think of an example?
A: Sure. I take care of a middle-aged man whose wife died a number of years ago and who has bone marrow failure; he's anemic. I took care of him for a number of years during which his transfusion needs slowly increased, which is typical. Then when I saw him six months ago, his transfusion needs had really gone up. If I had looked at him in a strictly scientific way, I would have said, ''Mr. Jones' anemia is worse; he needs more blood.'' But I noticed he seemed somewhat ill at ease. So I completely left the medical sphere and asked him about his home life. He had a girlfriend, and it turned out he was impotent.
Now, testosterone is a key hormone in stimulating red blood cell production in men, and people with long-term illnesses such as the one he has can get low testosterone levels. We measured his, and it was sub-basement. So we gave him testosterone, and it not only improved his sexual dysfunction, but his transfusion needs plummeted.
I had a gut feeling that something was changed with him, though I wasn't sure what it was. And because I know him as a person, and because he was comfortable with me, I could move into a social domain and find out something which many men wouldn't disclose.
Q: What about patients whose doctors don't know them well? Can a doctor exercise intuition within the constraints of managed care?
A: It's certainly one of the negative outcomes of managed care to have visits that are measured in single-digit minutes. Taking the extra time, being able to address social and psychological needs, not only may turn up an important medical fact but also improves the chances that a patient and doctor can explore prevention issues: wellness, diet, stopping smoking, for instance. If the goal is better health, we're defeating ourselves by not having that kind of doctor-patient relationship.
Q: You start your book by describing a crisis in which another doctor refused to believe that your son was very sick, and you and your wife sensed it was serious and challenged him. But you're both Harvard-trained physicians. What chance would an average person have of succeeding in a similar encounter?
A: I hope that reading these narratives will give people encouragement and courage to speak up. It isn't necessary to be adversarial --- just to say, in a very clear way, ''I don't fully understand that explanation, and I would very much like you to explain it to me again.'' There is nothing in medicine so complicated that it cannot be clearly communicated to anyone. And if it doesn't make sense to the patient, then either the doctor doesn't understand it or the doctor is not explaining it well.
Q: What if the doctor perceives the questioning as antagonistic?
A: The paradox here --- and this is what I hope will give people the most courage --- is that the more you articulate to the doctor, the more you help him or her figure out the diagnosis and craft with you the best treatment program. That verbalization --- that sort of offering of intuition and information from the patient and family --- can be absolutely vital. This understandable fear that doctors will be insulted and abandon you or in some way be vindictive --- we need to go beyond that.
Q: Surely that's asking for a lot of strength, at a time when the patient is debilitated and the family may be bewildered and afraid.
A: It is difficult, and it is most difficult for the patient. But the more that a patient and his family can articulate to the doctor, the better. Think of a patient who is very ill, with family members around the bedside. The family has known that person, in intimate ways, for much longer than the treating physician. I say to them outright: I want to hear from you. Please tell me what is happening. Please cry wolf: I would rather you cry wolf 20 times over vague symptoms than miss one important change. If a patient even says to me, ''I really feel lousy; I feel worse than I did yesterday,'' that means as much to me as all the results of blood tests and the blips on the cardiac monitor.
Q: You describe a case in which doctors absolutely disagreed about appropriate treatment, and another where a patient's diagnosis was never really settled. Will readers be surprised by the ambiguity that exists in medicine?
A: I expect so. It's hard, as a physician, to publicly expose your limits. Everything in medical training, from the starched white coat to the bearing and the language, is meant to project a sense of knowledge and control. But the truth is that there are many moments in medicine where there is no knowledge and there is not a firm sense of control --- and that again is a place where both the patient's intuition and the doctor's intuition are key.
Q: Is there advice that you can encapsulate for patients?
A: Two things. The first is the issue of asking for a second opinion. It is a critical step for anyone facing a severe illness, a treatment that has significant risk, an experimental therapy or a problem where the diagnosis is not clear. In that seeking of a second opinion, one should go to a specialist, at a different institution, who hopefully will have a different perspective or be able to objectively endorse the first opinion. The second is that the understandable hesitation that patients and families have to question a doctor or to ask for a clearer explanation, out of fear of alienating the doctor or seeming adversarial, is actually counterproductive. It is vital for a physician, in formulating a diagnosis and crafting a treatment, to draw on the intuition and information that a patient and a family can give. I want to encourage people to be more ready to do that, and therefore to form a real partnership in their own care.
ON THE WEB: Discuss Dr. Jerome Groopman's views with Dr. Stephen Balch: www.accessatlanta.com/living/health/
