WWWWF:
A Look at Wichita Falls on the Web

Man, covering trials just takes a whole lot outta ya.

Anywho, back to the book (and some insights from my first look at the text. If nothing else, I’ve learned that blog messages should be a bit shorter. Meh, I got excited and just went with it. Read to Achieve, you know?)

Chapter two boils down to understanding how prejudice and stereotyping exist even despite the best intentions and sometimes because of those intentions. It’s good to recognize that thinking, especially in light of how deep such bias may play in our culture. Groopman gives the term a more sterile phrase (part of a trend in the book that starts to make his writing less reader-friendly as it goes along), but the implications remain just as important.

Groopman provides insights into what he calls “representative," "attribution,” and “affective" errors. The first means a doc's thinking gets guided by a prototype and contradictory evidence get overlooked. In the book's example, a guy who looked fit and athletic wasn't thought to have heart problems, though he did. Attribution error is a lot more in line with stereotyping, in which folks who fit certain characteristics get short shrift, like this guy:

Charles Carver was in his seventies, retired from the merchant mrine and living by himself in a small apartment. Over the past months, he had felt fatigued and his belly had begun to swell. When Carver came into the ER, the intern noticed alcohol on his breath, and Carver readily told him that he enjoyed a glass of rum each evening. His legs and feet, as well as his abdomen, were swollen. Carver was unshaven; his clothes were old and frayed. The intern wondered to himself how many days it had been since he bathed.

The intern labeled the guy a drunk. Turns out Carver had Wilson's disease.

What Groopman really helps to get across is why such thinking can become such a big deal. For one thing, mental, medical and social ills can all look alike:

A young man was brought to the emergency ward of the hospital in the wee hours. The police had found him sleeping on the steps of a local art museum. He was unshaven, his clothes were dirty, and he was uncooperative, unwilling to rouse himself and respond with any clarity to the triage nurse's questions. Dr. Delgado was busy that night attending to other patients, so she "eyeballed" him and decided that he could stay on a gurney in the corridor, another homeless hippie who would be given breakfast in the morning and returned to the streets. Some hours later, she felt a nurse tugging at her sleeve. "I really want you to go back and examine that guy," the nurse said. ...

"His blood sugar was sky-high," Delgado told me. The young man was on the brink of a diabetic coma. He had fallen asleep near the art museum because he was weak and lethargic and unable to make it back to his apartment. ... His difficulties giving the police and the triage nurse information reflected the metabolic changes that typify out-of-control diabetes.

For another thing, technology won’t be the savior of mankind. For instance, Groopman explains that about half of anginas don't show up on EKG scans.

What helps all of these points is Groopman’s attention to details and frankness in his own shortcomings:

I examined his eyes, ears, nose and throat, and found nothing of note except some small ulcers on his inner cheeks and under his tongue, side effects of his treatment. Brad worked hard to take deep breaths when I examined his lungs -- they were clear -- and his heart sounds were strong, without a "gallop" indicating heart failure. His abdomen was soft, and there was no tenderness over his bladder.

"Enough for today," I said. Brad looked so peaked that it seemed wise to let him rest. He nodded his thanks.

Later that day, I was in the hematology lab, looking at the bone marrow biopsy of a patiet with leukemia, when my beeper went off with a stat page. "Brad Miller has no blood pressure," the resident reported when I called. "His temperature is up to 104, and we're moving him to the ICU."

Septic shock. When bacteria spread through the bloodstream, they can shut down the circulation. This can be fatal even in people who are otherwise healthy, but patients with impaired immunity, like Brad, whose white blood cell count has been lowered by chemotherapy, often die.

"Do we have a source?" I asked

"He has what looks like an abscess in his left buttock," the resident said.

Patients who lack the white cells to fight bacteria are prone to infections at sites that are routinely soiled, like the area between the buttocks.

I fell silent as I replayed in my mind the scene on rounds with Brad that morning. The abscess had certainly been there a few hours before. "Enough for today," I had said. Not enough at all. I had failed to ask him to roll over so I could examine his buttocks and rectum.

"We repeated his cultures and began broad-spectrum antibiotics," the resident said. "The ICU team will take over."

"Okay. Good job," As I hung up the phone, I berated myself further. Bad job. Sloppy job.

My heart had ached for Brad, and that deep feeling had caused me to break discipline [this is what Groopman calls affective error, or lulling oneself into thinking that what we want is what will happen because the scant info available confirms that hope] ... I hd not wanted to add further to Brad's discomfort. I left the bedsheets on him. That could prove to be a fatal mistake.