The Next Book I Buy

Been perusing some book sections of major papers while I watch exercise infomercials this morning and I ran across two on a new book by Jerome Groopman, "How Doctors Think." As I read the summaries of this examination of the way doctors diagnose and prescribe and the heuristics they use and sometimes get trapped in, I couldn't help thinking about judges, guidelines, and corrections sentencing policy. In both cases, we're dealing with a person before us who needs to be fixed through our intervention (and, yes, we are trying to "fix" offenders--that's why we call it "corrections"). And in both cases, reliance on a limited set of tools and ways of thinking can lead us to fail, with often disastrous results.

Here are some of the key points noted in the reviews. They're about doctors, but see if you can't see yourself subbing "judges" in the subject.

Groopman dissects doctors' thinking and neatly packages it into simple and accessible terms that suggest why it sometimes leads to faulty actions. He introduces us to terms such as "diagnosis momentum" — when a diagnosis becomes fixed in the mind of the physician despite incomplete evidence. Or "availability," which means the tendency to judge the likelihood of a medical event by the ease with which relevant examples come to mind. . . .

Along with what doctors think about medical management of illnesses, the author surprises us with stories of how doctors think and feel about patients and how it changes the care they receive. It is no surprise that a doctor who secretly dislikes a patient may rush him through or make him feel like he is on an assembly line, but Groopman also explores the unexpected effect of being liked by the doctor. . . .

Groopman gives a brief mention of how modern evidence-based medicine competes with the art of using your intuition. He touches on how drug and insurance companies pressure doctors as he vividly explores their influence via big drug company sales representatives. [TECHNOCORRECTIONS!!!!] I would have liked him to have written more about the influence of insurance companies, an area barely touched on, and about finances. This might have given readers a more complete picture of the intersection of medicine and finances. . . .

. . . misdiagnosis is “a window into the medical mind,” revealing “why doctors fail to question their assumptions, why their thinking is sometimes closed or skewed, why they overlook the gaps in their knowledge.” According to one study he cites, as many as 15 percent of patients receive inaccurate diagnoses, a finding that matches research based on autopsies. [Oh, for recidivism rates of only 15%.] . . .

Today’s physicians are increasingly encouraged to behave as if they were computers, and to reason from flowcharts and algorithms. This is intended to produce better diagnoses and fewer errors; it is also embraced by insurance companies, who use it to decide which tests and treatments to approve. This approach can be useful for “run-of-the-mill diagnosis and treatment — distinguishing strep throat from viral pharyngitis, for example,” Groopman writes. But for difficult cases he finds it limiting and dehumanizing. He is similarly critical of generic profiles, classification schemes that draw statistical portraits of disease states. They encourage the doctor to focus on the disease, not the patient, and so may lead him to miss the particular manifestation in the particular sufferer. . . .

Groopman reviews the clinical conference where [a very badly and repeatedly misdiagnosed] case was discussed. Such conferences occur at every teaching hospital in the country, Groopman writes, but they generally lack “an in-depth examination of why the diagnosis was missed — specifically, what cognitive errors occurred and how they could have been remedied.” He observes that the doctors at Boston Children’s Hospital, one of the best pediatric hospitals in the world, had extensive experience with SCID and similar genetic abnormalities: “Familiarity breeds conclusions and sometimes a certain degree of contempt for alternatives.” Physicians may be reluctant to pursue unlikely diagnoses, particularly if they will be criticized by colleagues for ordering too many tests or for being show-offs. . . .

This last quote raises a major question. Why is it that we see so few (any?) "clinical conferences" of failed sentences? I mean, I know that court systems are notorious for failing to provide and analyze their sentencing data themselves. If they had been doing so effectively, sentencing commissions would likely never have come into existence. But these reviews show what happens when professionals really care about the outcome of their decisions. When those decisions fail, they at least go through the motions of, and in many cases take seriously, figuring out why they didn't work.

It's not enough to say there are too many other parties involved. There aren't that many. The corrections folks, treatment people, counselors. Basically the folks who are making drug courts work right now. And you wouldn't have to do every case. Just the more egregious ones, say, when the reoffense is violent or hits a threshold of a certain number of offenses or is just randomly selected. I do know of judges who have made the effort a few times, but why isn't it done on a regular basis? Not just by them but by prosecutors who drop cases or agree to lower pleas to get the deal. More work and time? Well, we show our priorities by where we put our work and time. That we make no more effort to figure out how and why we're messing up tells the community all it needs to know about whether we consider sentencing well and improving and correcting our mistakes important.

That's one reason why we've been such strong supporters here of the "sentencing information systems" that are currently climbing on our sentencing policy Hit Parade. And why I'm so enthusiastic about what CO is proposing for its new sentencing commission (and what VT might end up with, from what I understand). Gather good data and get good people to analyze it for knowledge of "what works" and what doesn't. Feed the results back into the system and hold those who fail to pay attention accountable for their resulting failures. Health care and analysis of misdiagnosing benefited enormously from the move to evidence-based practice and consistent review of what practice achieved. Success in CO (and VT?) could move corrections sentencing far down the road to doing the same thing and making improved public safety and decreased victimization real possibilities. Maybe we could even start doing joint court-corrections "clinical conferences" to enhance the process even more. At least among the practitioners who want to do their jobs better. (And we can find out the ones who don't.) We have a chance to stop our twirling and arguing and to start making sentencing based on more than the limited actual number of possible sentences and factors now being used. Who knew that a book about doctors could offer corrections sentencing so much?

I got to get to the bookstore.