“Doctor, Step Away From That Cookbook!”

A middle-aged man develops chest pain at home. Minutes after calling 911, he’s in an ambulance, whizzing through traffic to the nearest emergency room. The paramedics radio ahead, and by the time the patient arrives in the ER, the hospital’s heart attack team has been activated. A stat electrocardiogram shows an ST-elevation myocardial infarction (STEMI), and suddenly It’s Showtime: the patient enters the “chest pain pathway,” automatically triggering a pre-prescribed set of actions: medications, blood tests, oxygen, and more. The cardiologists, nurses and technicians congregate in the cath lab, waiting for the handoff. Nothing is left to chance: the STEMI team even has a special key that allows them to commandeer the elevator.

This is life-and-death choreography – George Balanchine meets Dr. John Carter – and it works. In the old days, it might have taken 3 or 4 hours to get a catheter into the patient’s coronary artery. By following this cookbook approach, the patient’s blocked vessel is stented open within 90 minutes. And this scenario (and similar ones for patients with strokes and sepsis) plays out tens of thousands of times each day in the U.S. In a crowded ER, with its waiting room full of patients and where triage is the name of the game, nobody questions whether this is the right approach. It saves lives.

But, as the saying goes, when you’re a hammer, everything looks like a nail. In their new book, “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests,” Drs. Leana Wen and Joshua Kosowsky, emergency medicine physicians from Brigham & Woman’s Hospital (Wen, impressively, is still a resident; Kosowsky is an attending), argue that this cookbook approach has infected not only emergency medicine but all of medicine, rendering healthcare not only impersonal but unsafe. They write:

“Algorithms” and “pathways” have proliferated in ways that have reduced each person’s unique story to simplistic recipes…. Doctors end up adopting the role of automaton, following recipes and doing as directed, but no longer empowered to listen, to think, to diagnose, and to heal.

Wen and Kosowsky argue that we have entered an “era of depersonalized diagnosis,” in which we have…

come full circle, back to the time of the black box, when a visit to the shaman turns up a solution in the form of a random incantation or ritual. Today, doctors order a CT or MRI and expect the patient to emerge from the (literal and figurative) black box with an answer… There’s no thinking necessary. But at what costs to patients?

How does this actually play out? Take the patient who presents to the ER with a headache, some abdominal discomfort, and a little chest pain. Within minutes of arrival, the patient is forced, sometimes nearly bullied, onto a clinical pathway, as in “would you agree that your belly pain is your biggest problem?” The authors describe one poor college kid who came to the ER hung over after a night of partying. After she made the mistake of saying she had the “worst headache of her life” (which reflexively triggers the “Rule-out Subarachnoid Hemorrhage” pathway), she ended up with a CT scan, which was predictably negative. She would have ended up with a lumbar puncture too, if she hadn’t escaped out a side door.

I found this indictment of cookbook medicine-run-amok both interesting and, for the most part, persuasive. Where the authors began to lose me was with their other central argument: that the only way to improve this situation is for patients to serve as the agents of change. Accordingly, the book’s audience is not physicians – whom the authors believe are hopelessly stuck – but rather patients, whom they believe can force doctors to slow down and listen better… if they are suitably empowered and coached. “Make your doctor into the ideal doctor that you always wanted by showing them the way!” they write, with characteristic (over)exuberance.

Given the audience, I liked the book’s conversational tone; I was even okay with the potentially awkward device of having the two authors speak independently at times (Dr. Wen: “Supposedly Yolanda answered ‘yes’ to everything, and the one time she said ‘no,’ it turned out not even to be accurate!” Dr. Kosowsky: “That’s exactly the point. Close-ended questions have limited value…”). Complex concepts, including iterative hypothesis testing, Bayesian reasoning, and anchoring bias, are described simply and effectively, usually without their jargony labels (probably a good choice on the authors’ part). The reader is regaled with lots of clinical vignettes, many of them versions of this tale: A patient comes to the ER with a complaint, and ultimately receives the wrong diagnosis, or no diagnosis at all – a victim of cookbook medicine. In the end, the answer was right there all along, if only the doctor had taken the time to listen to the patient’s story.

And the book is chock-full of patient-oriented tools. After the authors describe an ineffective doctor-patient encounter, readers are presented with an alternative script, the things the patient might have said to better get her points across. Wen and Kosowsky also include a number of patient-oriented tools, including the “8 Pillars to Better Diagnosis,” “21 Exercises Toward Better Diagnosis,” and worksheets for patients to write down their stories before seeing their doctor. They do a nice job answering obvious objections to their recommendations, including the “I’m worried about being sued” argument that many ER physicians will raise when told that they should listen more and scan less.

While “When Doctors Don’t Listen” has a lot going for it, there are major problems – this patient needs resuscitation. Much of the writing is pedestrian, repetitive, and breathless (the term “common sense” appears 42 times, and if one got a nickel rebate for every exclamation point, the book would be free). Some of the devices are a bit cutesy for my taste (“+911 Action Tip”). In a book whose subject is preventing errors, it was disheartening to find at least a half-dozen typos (“Acknolwedgments”, “a big burley man”), and a few substantive errors (Dr. Herbert Chase is not “the founder of [IBM’s] Watson,” he’s a Columbia University medical informaticist consulting with IBM to develop the computer’s medical functions). The bibliography is weak; it gives little evidence that the authors have read many prior important works in diagnosis, such as Groopman’s “How Doctors Think,” Kahneman’s “Thinking Fast and Slow,” or most of the seminal academic articles on diagnostic errors and reasoning. Also, the book’s viewpoint is truly ER-centric, although one can see how the proliferation of disease-specific quality measures will generate more and more of this type of thinking (think: sepsis bundle) in other parts of the healthcare system. While granting that poor doctor-patient communication is a problem everywhere, the lens here is relatively narrow, a problem that the authors should have acknowledged and mitigated.

Moreover, the stories begin to wear thin after a while, particularly since, in them, patients always seem to know what is wrong with them, and the cookbook-addled doctor would also get it right if only he junked the pathway and listened more carefully. This heroic patient/clueless doctor narrative may feel good (to some), but it’s not always true. Every now and then, the patient who doesn’t place much stock on his chest and back discomfort dies of an aortic dissection. And sometimes the patient who goes on and on really is a blabbermouth who does need to be gently guided to focus on what really matters.

More fundamentally, while I agree with many of the suggestions to physicians (such as trying very hard to avoid leading questions and giving patients time to tell their stories), the admonition that we should be completely open with patients about all the diagnoses we are considering (“I think you have pneumonia, but I can’t be sure you don’t have lung cancer,” they’d have doctors say) and what we’re looking for as we go through the physical examination is a recipe for unproductive anxiety, for both patient and doctor. And relatively few patients – even after completing all of the book’s exercises (and really, who is going to do that?) – will be able to be as blunt and forward as the authors recommend. (To the ER doc running out of the room after recommending a CT scan, they advocate that the patient say, “Actually, doctor, I’m not OK with that”.)

The book’s emphasis on what patients can do to protect themselves is a clever premise, and – as they say in the PR business – a nice “hook.” It will boost sales, it will get the authors booked on the morning talk show circuit, and it will excite people who mistrust the medical profession or who yearn to regain some control in what can feel like a lopsided power relationship. Yet to me this emphasis seems fundamentally misplaced, and even risks blaming the victim. Patients can help, sure, but they are not the crux of the problem, nor should they be the focus of our search for solutions.

The key test, of course, is whether this approach will actually improve patient safety? For most patients, sadly, I doubt it.

Would I buy this book? If I were a patient who was having lots of medical encounters (particularly ER visits) and was invested in trying to improve things, I might find it useful. And emergency medicine physicians, and those who set ER policy, would do well to reflect on its cautionary notes regarding the slippery slope of cookbook, algorithmic medicine. But for everyone else, probably not.

9 Responses to ““Doctor, Step Away From That Cookbook!””

  1. william reichert January 27, 2013 at 9:59 pm #

    Let me explain something to you.Thinking is not welcome in today’s medical environment.

    Case #1

    As the hospitalist covering the ER I was asked to come admit a patient with a stroke. “All we need is orders”, the ER doc said. WE need to get her up in to a room ASAP .
    I entered the patient’s room and sat down to talk. What is your problem tonight?
    My left arm is weak. How long has it been weak? Oh, for about 3 years but a little worse tonight
    so I thought I would get it checked out..
    After exam I suggested she had a problem, needed to see a neurologist. but nothing needed to be done tonight. I arranged the appointment, My boss was in the ER, I explained the situation and he accused me of being lazy, not wanting to admit the patient.

    Another night, I was asked on behalf of an orthopedic surgeon to admit a young woman with a fractured femur. Turns out
    she was bedridden with paralysis of both legs for the past 6 years. No sensation in the legs.
    I thought ( my sin) well: does she need surgery? What good would it do? SO I suggested that
    the orthopedic surgeon come in and evaluate the patient imself to see if he thought surgery was indicated.If not, an admission would be not needed. The surgeon was furious. Demanded
    I admit the patient. I refused. So he came in, saw her and sent her home/.

    I did not make friends those nights.

    I’ll tell you a better one. Got word that the pulmonary guys wanted to be consulted on every
    patient admitted to the ICU. I thought,”great: get evaluated right away during the “golden hour”. Get them intubated, lines inserted, discussions with family about code status,etc.

    BUT NO. They would come in THE NEXT DAY. I said in ICU meeting that this would
    be too late to have the biggest impact on patient care since by then many of the critical
    decisions had already been made. The committee looked a me like I was speaking
    Mandarin or something.

    Dont rock the boat. Play the game by the rules the group sets up. Thinking is subversive
    in medicine.

  2. Stan Jackson, MD January 27, 2013 at 11:03 pm #

    The unintended consequences of cookbook medicine are extensive, and create illness in patients, incorrect treatments, inappropriate radiation, and delays in diagnosis. They are expensive and unsafe. Bob, you seem to not want to know that the emperor is bare.

  3. Menoalittle January 28, 2013 at 1:14 am #

    Bob,

    The book could just as well be entitled, “doctor and nurse, stop burying your face in the computer screen” or “doctor and nurse, I am the patient, the computer is not”. It is a commentary on a much bigger picture than you portray.

    Yet, in a profession in which subtle differences and nuances make all of the difference in arriving at the correct diagnosis, health care professionals’ cognitive power is now being devoted to the machine, the EMR, the CPOE, and the oft flawed digital cookbook, clinical decision support, aka CDS. How in the world do these error producing medical devices become central infrastructure in hospitals?

    Don’t say that you were not told that these devices are bringing about regressive changes in how doctors take care of patients to the detriment of all concerned. There is change all right, with negative progress.

    Bob, your silence on the newly deployed CPOE systems at UCSF is deafening. Are you under a gag order? Will there be retaliation if you tell the truth?

    Best regards,

    Menoalittle

  4. William Allen, MD January 28, 2013 at 7:28 pm #

    My father was a fighter pilot and tried to teach me to fly ( a mistake). Pilots have checklists for takeoff, checklists for landings, checklists for stalls, checklists for any emergency. But the checklist was always a starting point, never an endpoint. It got you thinking, moving and acting. It was never ‘checklist versus thinking’. You were always expected to use the checklist and your brain. So I question the whole premise of the book because I see physicians using both checklists and brains.

    • Mark Rosen January 29, 2013 at 11:28 pm #

      Agree with thinking in the context of some guidance, when needed, for what is usually the right approach.

      If you’re a master chef you don’t need a cookbook, you write it. If you can’t cook, use the book.

  5. Dr. Leana Wen January 28, 2013 at 7:53 pm #

    Dr. Wachter–wow, thank you for writing a review of our book! I’m extremely honored.

    Your points are legitimate and article very well-written. If I may address just one point: you’re right that blaming the “victim”, the patient, isn’t a good approach. The best way is to get doctors, and our healthcare system, to change. However, in the absence of change from them, at least patients should be empowered to get the best care they care. That’s the angle our book takes: to give tangible tips and how-tos for taking control of your health (for example, the 8 pillars to better diagnosis).

    Really honored again that you read our book. Many thanks, and I hope to continue the discussion.

    Leana Wen

  6. Shirie Leng February 20, 2013 at 3:46 pm #

    Protocols are good and bad. In the OR, if a case is flagged as having a protocol attached to it, it alerts caregivers that certain specific, special, or unusual requirements or equipment is needed. The problem with this is that it eliminates any requirement for thinking, and creates a superior/inferior atmosphere between surgeon and everyone else. The conversation is not “What does this patient need?” but “What does Dr. x want for his ABC cases?”. You don’t need an MD to just do what someone else wants.

    In the ER, I suspect things are protocol-driven because of liability issues. “Well your honor, I thought…” is less effective in defense than “Your honor, this is the hospital-established protocol.”

  7. Anna Gardiner February 23, 2013 at 4:55 am #

    I heard the authors speak on their talk-show tour. As a patient who became disabled a decade ago as a”hot potato” outpatient with no diagnosis, I found only a few exceptional doctors open to patient involvement in their care. Most got defensive when questioned. I was always respectful. Society still largely sees outspoken patients as non-compliant and troublemakers.

    Once a defensive doctor gets his guard up, the encounter goes south quickly and the patient does not get quality care. As other commenters noted, even doctors were admonished for thinking. How do you think doctors (with some exception) view patients who think? Largely as time wasters.

    Nothing will change without collaboration among all players.

    The best advice you can give patients is to have them read and learn all they can about their maladies and what it takes to diagnose and treat, including lifestyle changes (diet and exercise.) Tell them how to research to find the best doctors and to wait to see them even if it takes months to get an appointment. I wish someone had given me this advice when I placed my faith in a flawed medical system. The lesson cost me everything I had including my health.

  8. Sharon Eloranta February 26, 2013 at 12:30 am #

    I think this group (including Dr. Wachter) is conflating “cookbooks” with “standardized processes.” Highly reliable organizations such as aviation, nuclear power, etc., have reached six-sigma reliability by creating standard processes to follow standard inputs. Any standard only has to work 80% of the time, because mitigation steps and FMEA are built in – to continuously improve the process. The exception to “standard” in medicine can ONLY come from the patient – he/she is not clinically eligible for the treatment or, after shared decision making, refuses the treatment. The 80% rule and the “patient exception’ leave plenty of room for individualized treatment planning. What the standard steps ensure is that if the patient REALLY has the problem (STEMI, no one doubts it) then there is a standard path to ensure reliable care. Should the team waste their time thinking up how to get the patient to cath lab? NO! there is a standard for that, so the team can spend their time thinking about any atypical features that occur.

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