Things seem to have ground to a halt by Chapter 8.

The detailed description of medical community life is there, as Groopman plunges into the world of radiology and the pitfalls of gestalt reasoning.

And the scary insights and sobering stats are also present.

One film of the sixty was of a patient who was missing his left clavicle. Presenting such a chest x-ray was meant to assess performance in noticing what was not on the film rather than merely searching for a positive finding -- an exercise that points out our natural preference for focusing on positive data and ignoring the negative, as James Lock emphasized. Remarkably, 60 percent of the radiologists failed to identify the missing clavicle.

But the narrative seems to have flown by the wayside. As he delves deeper and deeper into medical terminology and pschoanalysis behind the mistakes being made, the chapter just loses steam. You can only read about CT scans, anterior cruciate ligaments and "interobserer variability" so many times before you start to shut stuff out.

Patients can help the doctor think by asking questions. If he mentions a possible complication from surgery, they can ask how often it happens. If he talks about pain and lingering discomfort from a procedure, they can ask how the pain compares with having a tooth pulled under Novocain, or some other unpleasant event. If he recommends a procedure, patients can ask why, what might be found, with what probability, and, importantly, how much difference it will make to find it. Some physicians will be uneasy, some even angry, when queried this way, because they may not have all the answers. Others will take the time and clearly respond to these simple, direct, reasonable questions. The kind of response illuminates how much the doctor really knows about your case, and how much still needs to be discovered.

For doctors, there's also a plethora of insights. For one, bedside manner counts.

Paradoxically, such confidence is bolstered, Light said, when a physician opens his mind to a patient and explains what he knows and what he doesn't know, what is firm about his findings and what is still unclear, which symptoms he can account for and which still demand explanation.

And

This was another message that Dr. Light believes surgeons should communicate to their patients, especially in advance of an operation. "The perfect is the enemy of the good," Light said. "Nothing that you do in surgery is perfect. Everything is a compromise." ...While you cannot predict a specific outcome for any particular patient, Light emphasized, you need to be candid and not paint too rosy a scenario.

Over the course of three years, the patient had consulted six hand surgeons and got four different opinions about what was wrong and what to do about it. I was that patient.

But the hits keep coming. For instance, with the makeup of our bodies

"Often we don't know what accounts for symptoms of pain in the hand, given that almost everyone has a hole in a bone if you look hard enough."

Or the necessity of operations.

Dr. B studied in detail every unusual shadow and shape on my x-rays and MRI scan. In addition to the cysts in the scaphoid and lunate bones, he noted a tiny cyst in the another bone, on the pinkie side of the wrist. The tendon that runs toward the pinkie also seemed to have slipped slightly out of position. Dr. B thought there was a hairline fracture in the scaphoid bone, not simply a cyst. He said that I needed three surgeries. ...

Dr. Terry Light said, of course, that to comment properly on Dr. B's opinion, he would hae had to examine me and view the MRI; but the idea of three surgeries to address every finding on the scan -- this gave Light pause. "That's the problem with MRI. It can show us way too much."

My favorite is the guy who just makes something up.

At each follow-up visit, I pressed Dr. A for answers. He would just shrug. Then, a year after I first consulted him, he said, "I think you have developed a hyperactive synovium." The synovium, the lining of the joints around the wrist and hand, Dr. A explained, had become too sensitive to endure even minor stresses. It overreacted by becoming inflamed. He suggested a surgical procedure to strip away all of it. ...

I am not a specialist in diseases of the ones and joints, and I'd never heard of a "hyperactive synovium." Niether had Dr. Light: he said that the diagnosis "didn't register. It doesn't really mean anything to me.

Dr. A had come to the end of his thinking. But instead of returning to the honesty of "I really don't know," he invented something to respond to my plaintive questioning and suggested an operation that could be damaging.

The remedy is to get someone else in the room to bounce ideas off of. Groopman took his wife.

Pam had been quiet, communicating through glances with me. As I read the paper, she began to question the resident, politely but pointedly. She wanted to know how long the procedure took, what the likelihood of each complication was -- not just a list of possible complications -- and how long it took to recover.

All of it made me come up with a new company idea: Medical Buddies. Get a group of retired nurses, nurses assistants, etc., and hire them on a contract basis to just accompany folks on visits to the doctor when they think something serious is in the offing. That way, a lot of the questions a medical professional might have can be used to benefit a patient.

The alternative -- i.e., the here and now -- is just frightening to contemplate.

For instance, Groopman is once again does a good job of delving into medical behind-the-scenes to stop you cold.

"Most of what we do in pediatric cardiology, we make up. In fact, a fraction of what is routinely done today in my specialty, I made up," Lock said with a grin. That is because children often have such unique problems with their hearts that there is little precedent. But, Lock continued, "you simply have to do something. The big problem is that most people assume that once it's made up, it's actually real. Especially the people who make it up themselves. Then they think it came straight from God."

And this little tidbit

One of the most common congenital abnormalities of the heart is a hole between the two upper chambers, between the right atrium and the left atrium. Since the pressure in the left side of the heart is higher than in the right, blood will flow from the left atrium through the hole into the right atrium.This aberrant blood flow is called a shunt and can overload the right side of the heart, leading to heart failure and other complications. Lock told me that doctors send children for surgery to close these holes if there is a two-to-one shunt, meaning that twice as much blood flows through the right side of the heart than the left.

"Do you know where that two-to-one number came from?" Lock asked. I imagined it was from careful clinical studies of children with the hole. "You would think so. But you'd be wrong. At a medical meeting in the 1960s, a pediatrician presented the question 'When should the hole be closed?' to a group of cardiologists. There was a heated debate about how much shunting required a surgical fix. So the meeting organizers, out of desperation, took a vote. Some voted for a lower number, some for a higher number. The median ended up being two-to-one. ... Children can have two-to-one shunt and still have a good chance of being healthy and never needing any specific treatment. Many children with two-to-one shunts undergo surgery and probably don't need the operation."

But sometimes things just get to cluttered with clinical terms and too-technical explainations

Lock took a blank sheet of paper and began to rapidly sketch the outlines of the heart, its chambers and valves. There was a disorder called "common AV canal," he said, where the wall between the left and right sides of the heart does not fully form. This most often occurs in children with Down yndrome. "The central part of the heart is missing, and this can include the lower wall between the atria, part of the mitral valve and part of the tricuspid valve, and the upper wall between the ventricles -- all don't form." Some of these children also have aortic stenosis, Lock explained, meaning partial closure of the aortic valve, or co-arctation of the aorta, meaning that the large vessel is narrowed "When this happens, the left ventricle can be very small."

What it boils down to is making sure you consult as many specialists as possible to overcome their tendencies to overvalue their treatments while dismissing others. Not a bad idea, just one that gets hard to see through some of the writing.

Physicians should caution themselves to be not so ready to match a patient's symptoms and clinical findings against their mental templates or clinical prototypes. This is no easy. In medical school, and later during residency training, the emphasis is on learning the typical picture of a certain disorder, whether it is a peptic ulcer or a migraine or a kidney stone. Seemingly unusual or atypical presentations often get short shrift ... Another echoing maxim on rounds: "When you hear hoofbeats, think about horses, not zebras."

Moreover, since most birth mothers are themselves unmarried, they reject the idea of another single woman receiving their baby. Only two countries readily allow assignment of infants to middle-aged single women: Vietnam and Guatemala.

About breathing

Normally, the air we breathe is 20 percent oxygn and the remainder largely nitrogen with a small amount of carbon dioxide. Our lungs are built like a honeycomb, and the sacs in this honeycomb are called alveoli. The oxygen we inhale passes through the thin wall of these alveoli into the bloodstream. When bacteria and mucus fill the lungs, as in pneumonia, it is difficult for oxygen to pass through the clogged sacs and into the blood.

About eating

The most common form of malnutrition and immune deficiency in poor countries is due to the lack of adequate protein, as in severe starvation.

About nutrition

Furthermore, aside from relatively common dietary deficiencies -- lack of vitamin B12 causing pernicious anemia, or insufficient vitamin C giving rise to scurvy -- little is known about the effects of nutrition on many bodily functions.

A child starts having severe pneumonia and when all the doctors determined it was SCID, animmunodeficiency disorder, the mom refuses to discount the counter-evidence. She ends up helping doctors discover the true cause, a nutrional deficit.

The best thing about the chapter is depth about medical techniques and technology, giving a real sense of the action.

"There is one last resort," the ICU doctor told Rachel. "ECMO."

Rachel's thoughts moved slowly. "What is ECMO?" she asked in a whisper.

ECMO, he explained, stands for extracorporeal membrane oxygenation. It is a process whereby Shira's blood would be freshened with oxygen outside her body -- thus "extracorporeal" -- via a specialized machine. First an incision would be made in her neck and a large catheter inserted to drain the blood out of her veins into the machine. Inside the apparatus, the blood is percolated over a broad porous membrane. Then oxygen is pumped up through the membrane into the blood. At the exit, a pump returns the oxygen-enriched blood to the body. In essence, ECMO acts like an artificial lung and heart.

But Groopman also gets into some problems with his narrative, particularly as he tries to build sympathy for the mother. Groopman puts in so much work -- a lot of it to get across the woman's religious convictions that just seems forced -- that sometimes the message gets lost. Take this, after the child is helped but the mother learns of 9/11.

Rachel stood frozen in the room and felt as if her heart, so full of joy, were being torn. At the moment she celebrated Shira's restored life, thousands were likely dead in the attack on the World Trade Center. How can I rejoice when God's creatures are dying?

Laying it on a bit too thick for me.

Well, by the end of the story, Groopman's gotten to his point: "Rachel Stein was not an expert in cognitive psychology and did not study errors in medical decision-making. She was a desperate and frightened mother. But she found the strength to educate herself about her child's plight. And when she found inconsistencies in the many doctors' reasoning, she politely but persistently refused to e deterred. She diverted the boulder."

It was just a little difficult to see the forest from the trees thanks to all the paper filled with the winding tale.

Chapter 5 helps bring the notion frighteningly home.

Groopman paints a picture of "gatekeepers," those medical professionals who help steer patients in other directions, whether that's a specialist or a trip to the sofa, such as pediatricians and family practice folks. What really comes through, though, is how the patient loads needed to make a living as a physician can lead to oversights while the insurance companies that have come to dominate payment structures can demand changes in those thought processes. Groopman uses a great analogy of those caseloads, comparnig them to a passing train "Imagine watching a train go by. You are looking for one face in the window. Car after car passes. If you become distracted or inattentive, you risk missing the person. Or, if the train picks up too much speed, the faces begin to blur and you can't see the one you are seekin. 'That's what primary care medicine is like,' Victoria Rogers McEvoy told me."

The good doctor also gives good insight on how far the insurance pull is. Take this nugget on how a pay rate got established:

Many primary care physicians find their practices taking on a similar frenetic quality, and for similar reasons. Insurance companies seriously underreimburse doctors for primary care, a legacy of the period when surgeons headed the medical societies that negotiated with insurers about what was a "customary" payment for services. A specialist who performs a procedure -- a brochoscopy, say, or a surgical operation -- gets a substantial payment form the insurance carrier. But if a pediatrician or another primary care provider, a general practitioner or internist, spends an hour with a complex set of medical problems trying to arrive at a diagnosis, or probing the emotional fallout from an illnes or its treatment, the payment is meager. For this reason, many general pediatricians 'feel like they are running up a hill of sand,' McEvoy said.

Scarier still, here's a look at insurance companies' sway:

Not long ago, one of my neighbors told me that she had returned from a visit to her internist, who is a member of a large practice in a Boston hospital. I know the internist, and he recounted to me that he had recently been instructed by the practice's administrator to cut thirty-minute visits for follow-up to fifteen minutes, and sixty-minute appointments for new patients down to forty. When the doctor protested, the administrator told him that there was an electronic solution to make this all possible -- a template would be on his computer screen. As he spoke with a patient, he would fill in the form. This would help, the administrator added, not only in economizing his time but also maximizing his revenue, since it would make it easier for the billing office to submit invoices to insurance companies based on his template documentation of the history, physical exam and treatment recommendations.

Eric Cassell expands on the danger that clinical care is being squeezed by the efficiencies of the marketplace: "In healthcare planning, it is natural that each service might be seen as a commodity or product. The calculus involved in determining the cost of providing the service, the factors affecting reimbursement, the required number of such services, and other factors all promote the commodity view ... Medical care -- in all of medicine, not just primary care -- is a human interaction between patient and doctor within a context and in a social system. As such it is not a commodity."

Then it comes back to haunt folks in pediatric settings

In the course of a day, a full-time pediatrician may see two dozen or more children

In fact, a recent study showed that over the past decade, taking inflation into account, the incomes of physicians like pediatricians have fallen. Many doctors have reacted by truncating visits to ten to fifteen minutes and increasing the volume of patients they see in a given day. This speeds up the train and fosters the kinds of errors that Pat Croskerry and Harrison Alter fear when the ER doctor is spinning plates. Working in haste can not only increase cognitive mistakes but impair the communication of even the most basic information about treatment. A study of 45 doctors caring for 909 patients found that two thirds of the physicians did not tell the patient how long to take a new medication or what side effects it might cause. Nearly half of the doctors failed to specify the dose of the medication and how often it should be taken."

I've always been quite happy with the health coverage offered by the paper (the big joke with a co-worker is that the insurance is the real reason my wife married me since she has three kiddoes from a previous marriage), but in the big scheme of things, the fiscal control such companies wield over health care may be at the root of some of the problems.

[H]e recites the ABCs he learned during his training ... "A stands for airway, meaning that the mouth, throat, trachea, and bronchi are all open; B is breathing, that the patient's lungs are able to get enough oxygen and pass it into the bloodstream; C is circulation, that the heart is pumping, the blood pressue is adequte for the blood to reach vital organs like the liver, kidneys and brain..."

And he knows the pressures

"I'm coming up with nothing," Croskerry told the triage nurse. Nonetheless, he said he was sending off blood and urine tests. This was met by considerable resistance. "Why are you doing this?" the nurse asked. "She's already been worked up." Croskerry told me he felt "palpable" pressure because it was hectic in the emergency department and the nurse needed Maxine's bed for another patient. But he insisted. About an hour later, her test results were in hand, all normal. "I reassured her that this seemed to be her irritable bowel acting up," Croskerry said. "I went over again issues about proper diet and stress management. I also emphasized to her not to be reluctant to come back." Croskerry has learned from experience never to discourage patients from seeking follow-up care.

"She broke into tears, crying that no one believed her, that no one was able to come to a diagnosis," he recalled. "She kept saying that the pain was getting worse, that it was much worse than it had been even a week before." ... He sent he home. A short time later, she was rushed by ambulance back to the ER. "She collasped while walking home," Croskerry said. She was bleeding internally and on the verge of shock. She was rushed to the OR, where a surgeon found that Maxine had a ruptured ectopic pregnancy. "It had been missed three times. I was the third miss," Croskerry told me.

And he knows the pettiness (here, I wrote a note to myself that just said I'm shocked anyone survives being in a hospital with this kind of thing)

The ecology of an emergency department includes not only patients, their families, and, of course, nurses, but also other doctors. At Highland Hospital not long ago, Alter was the attending physician when a resident in training evaluated a man in his thirties complaining of a sore throat. "It's an open-and-shut case of strep," the resident told Alter -- an "uncomplicated" patient. Alter had the sense that the resident wanted to move quickly to his next patient. Alter asked for details. "He has an exudative pharyngitis, pus near the tonsils, and painful lymph nodes," the resident siad. Alter insisted that he wanted to meet the man himself. The resident sighed in frustration.

Alter peered into the patient's throat and saw no signs of pus. He ran his fingers along the sides of the man's neck and felt small, soft lymph nodes tha were not tender. Alter pressed more firmly on them. Still no reaction from the patient. The resident had already given him a large dose of antibiotic and a prescription for more.

Alter led the resident into the corridor and told him that it didn't at all look like strep, that it was most certainly a virus causing the sore throat, and that prescribing antibiotics unnecessarily could have serious consequences. ...

A short time later, another man came in with a sore throat. "Go to room 23 and start with the patient," Alter instructed the resident. After Alter had sutured the arm of a man with a knife wound, he made his way back to room 23. "he's fine," the resident said curtly. "Another one of your favorite viruses."

Alter didn't just sign off on the resident's assessment. As he interviewed the patient, he saw that he was restless, moving around on the examining table, unable to find a confortable position to rest his head. When Alter peered into his mouth, he saw nothing abnormal. The man was breathing easily, and there was no stridor, no harsh sounds suggesting an obstruction in the upper airway. But Alter was concerned about the patient's restlessness and his fever of 101 degrees F. He lingered awhile, thinking.

"Like I said, it's a viral pharyngitis, and at Highland Hospital we don't give these people antibiotics," the resident said with dripping sarcasm. Alter ignored the baiting tone. He again moved his fingers down the sides of the man's neck, marching meticulously, this time pressing inch by inch. When he was about halfway down, the man winced in pain.

"I want a CT scan of his neck," Alter told the resident. For a long moment the juniotr doctor said nothing, but then he left and ordered the scan. The call later from the radiologist did not surprise Alter: the man had an abscess in his neck. "This is the kind of infection that can kill you," Alter said. "If it's not treated quickly with intravenous antibiotics, it can block the upper airway and you'll suffocate."

Chapter 3 more than anything reinforces the importance of an informed patient, and not so much because people should know so much about their ailments so they can relay a lot of insight to their caregivers (though that's a good idea, too). No, what really sticks with me in this chapter is just how often someone had the guts to stick to their guns and not back down from wanting procedures despite the grumblings of their doctors. Some folks are born with that skill, but it's something everyone can develop once they have a little knowledge in them.

What Chapter 3 really looks at the way doctors and hospital operations can actually interfere with how healthcare gets delivered. The mental shortcuts doctors use can be skewed.

For one thing, there's the fault of "availibility" error, in which physicians "the tendency to judge the likelihood of an event by the ease with which relevent examples come to mind." So, if the area has a lot of allergies, then doctors maybe more apt to say an ailment is an allergy just because so many have come through the office. Then come tricks called "confirmation bias" and "anchoring," essentially selectively accepting facts that backup a hunch while downplaying contradictory notions and then hitching a diagnostic to a single hypothesis without considering other ideas. It adds up to situations in which misdiagnosis occur.

Battling against such problems comes from not being timid. Groopman offers some good advice on this front:

If the physician is distracted, frequently interrupted by other doctors, nurses, social workers, or the administrative staff as he interviews or examines you, the steady flow of his thinking may be diverted in the wrong direction. There is similar cause for concern if the physician seems rushed or breaks in as you answer a question, so that you feel he is not letting you tell him everything about your symptoms ...So a fair question to ask an ER physician is: What's the worst thing this can be? The question is not a sign of neurosis or hypochondria; in fact, residents are trained to keep it in mind with each patient they see.

Plus

Another way that laypeople can focus a doctor's attention is to ask: What body parts are near where I am having my symptom? This sounds elementary, but this query can help avoid "yin-yang out" errors

The yin-yang thang refers to doctors thinking every procedure that should be done has been done without making sure some new avenure gets explored. And finally

"No one -- no doctor, no patient -- should ever accept, as a first answer to a serious event, 'We see this sometimes,'" Alter said. "When you hear that sentence, reply, Let's keep looking until we figure out what is wrong or know the problem has passed."

Patients have to be on the look out because so much stuff can steal the focus they need from their providers.

Rather, Delgado believes, patients and their families should be aware that a doctor relies on pattern recognition in his work and, understandably, draws on stereotypes to make decisions. With that knowledge, they can help him avoid attribution errors.

"It's not easy for laypeople to do," Delgado said, "because patients and their families are especially reluctant to question a doctor's thinking when their questioning suggests his thinking is colored by personal prejudice or bias." Still, Delgado thinks laypeople can diplomatically direct a doctor's attention to his reliance on stereotypes, because on of her patiets had done this with her.

That brings us to the neat stuff, namely just how fascinatingly weird the human body is. The patient that talked to Delgado was Ellen Barnett.

Ellen Barnett had already consulted five physicians and felt all five had shunned her. "I'm having what I call explosions, feeling hot all over, which make my skin crawl. I mean really crawl, like ants all over, and sometimes they come with terrible headaches," she told Delgado. "Really, it's like a bomb going off in my body. I know I am in menopause, and all five doctors told me that that's the cause of my problems. And two told me that I'm crazy. And, frankly, I am a little crazy."

That kind of candor helped the doc overlook the obvious menopause diagnosis and uncover the neat biology:

"I evaluated her very extensively," Delgado said, "and it turned out that, yes, she was menopausal, and yes, she was a strange person with lots of weird ideas, but what turned up in her urine was not from menopause or being kooky. Her catecholamine levels were through the roof. A CT scan showed a pheochromocytoma above her left kidney."

A pheochromocytoma is a relatively rare endocrine tumor that produces catecholamine, chemicals like adrenaline that can cause wild swings in blood flow and blood pressure. The changes in circulation may mimic menopausal hot flashes and precipitate severe migraine-like headaches. The catecholamines can also cause psychological symptoms such as anxiety, despair and even aggression. If untreated, the patient may have a stroke or heart or kidney failure.