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Lions Roar : September 2007
SHAMBHALA SUN SEPTEMBER 2007 83 amples and personal experiences that illus- trate how the major- ity of medical errors are due to flaws in physician thinking. He illustrates how language and com- munication, with all the modern advances in technology and treatments, still form the bedrock of clinical practice. Entering the patient’s world through his or her story requires the use of both intellect and intu- ition, an ability that is fostered by years of training and experience, attention to detail, active listening, and psychological insight. These are all core competencies of the effec- tive health care practitioner. Unfortunately, many of these qualities that constitute em- bodied self-awareness seem to be missing from the skill set, or pharmacopoeia, of many physicians. Most people assume that medical decision-making is a rational and objective process, one that is free from the intrusion of emotion. They may be surprised to learn of the effect of a doctor’s feelings on the medical experience, and how, when unexamined, unrecognized, or unaccepted, these feelings can influence the course of a patient’s illness and life. Take, for instance, the case Groopman shares of a woman whose physician feels an aversion toward her, assuming her illness is psychosomatic. That physician is likely to fall into the trap of premature closure in his decision-making. A different doctor, however, one with the ability to approach this patient with curiosity and a beginner’s mind, may be able to produce a completely different (and far more satisfactory) outcome. Groopman skillfully uncovers a num- ber of cognitive errors common to the busy medical practitioner. The “repre- sentativeness error,” in which thinking is guided by prototypes and other possibili- ties aren’t considered, corresponds to the difficulty people have in bringing fresh eyes to a seemingly familiar situation. In the “attribution error,” a patient is defined by a negative stereotype, such “alcoholic” or “smoker.” These are people who are thought to take poor care of themselves, and thus are treated as less deserving of the clinician’s time and attention. Alternatively, decision-making that is driven primarily by a physician’s affections may result in an “affective error.” “Patients and loved ones swim together with phy- sicians in a sea of feelings,” Groopman writes. “Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents.” The ability to recognize feelings of aversion and attraction can act as a warning for the physician against the tendency to commit these types of errors. Groopman illustrates other cognitive errors via case discussions, as well as expert opinion on medical decision- making, neuroscience, and physicians who exemplify the qualities of self-awareness, curiosity, openness, and professionalism required to be of true service to their patients. Several themes emerge, especially the importance of knowing how the physician knows what he or she knows and of regularly questioning assumptions made about that knowledge. Knowing the limitations of knowledge— the presence of uncertainties and para- doxes, the unpredictability of outcomes, the pressures of conformity and orthodoxy in medicine—is crucial to avoiding cogni- tive errors. The self-aware practitioner can share some of these difficulties with pa- tients in a sensitive and open manner. And, Groopman maintains, the patient, by ques- tioning openly and seeking understanding, can help the physician recognize the threats posed by misguided thinking, making pos- sible more effective medical care. The Hippocratic oath, one of the old- est formal vows in recorded history, asks the physician who is about to take on the responsibilities of medical practice to com- mit to something that extends beyond the self. In one modern version, the covenant includes the following affirmations: I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over-treatment and therapeutic nihilism...I will remember that there is art to medicine as well as dd photo with guanyin shot by in SanFrancisco samOvar tea Lounge am am m m Ovar Ovar Ovar Ovar tea tea teaaa @ pacificzen.org (707) 538.9340 (7am-7pm + SEPT 72-99.indd 83 SEPT 72-99.indd 83 6/25/07 5:30:28 PM 6/25/07 5:30:28 PM