Medicine of Friendship

Clinical wisdom is genuine relationship between a doctor and his patient. Clinical wisdom involves both technology and human touch. It is not only knowledge about human biology, but also knowledge and understanding about how the mind of the doctor and patient gets attuned to arrive at the right diagnosis. It is believed that the majority of misdiagnoses are related to cognitive biases.

Daniel Kahneman and Amos Tversky have defined a series of thinking errors. Anchoring is a common human tendency to rely too heavily on one trait or piece of information when making decisions, rather than considering the full array of potential information. Availability error emanates from “what is more available in memory”, specifically cases recently seen or ones that made a deep impression on us. Due to “attribution” error we conform to fit social or cultural stereotypes in our minds.

Understanding the reasons of misdiagnosis can be helpful for a physician. Misdiagnosis as a result of anchoring often is based on the information that is not enough for right diagnosis. For example, during a flu epidemic, a patient comes to the doctor with flu like symptoms. If the doctor’s mind is biased, he may ignore a few other findings that are important for the diagnosis and make an error in his medical judgment. Misdiagnosis due to availability error could be due to biased preconceived notion about a patient. The patient may not be as alcoholic as the doctor presumes him to be, as a result, diagnoses enlarged liver due to alcoholism. Jeromy Groopman writes, “The stereotype in our mind tends to bias our thinking and lead us to a premature conclusion.”

It’s not so much about what one thinks but how one thinks. Metacognition is the ability to think about our thinking. It teaches us about the elements that control our thoughts. It determines whether one can dismiss them or sink into prolonged and deeper distress. Metacognition recognises that our minds can be imperfect. It recognises that our assumptions can be biased and wrong. It tells us to take decisions after considering everything that should have been considered. It embodies the concept of humility.

Metacognition is essential for clinical wisdom, as the minds of even the most accomplished doctors can be imperfect. These imperfections get amplified under time pressure and uncertainty. In our hospitals with so many patients, doctors can’t give enough time to individual. Long serpentine queues and limited infrastructural facilities intimidate them. They are pushed to make rapid judgments and shortcuts. Learning the virtues of metacognition, doctors can avoid falling into the trap of misdiagnosis. Groopman says though best practices developed by experts and optimal treatment based on statistical analysis is important, more important is how these apply to the individual patient. Medicine of friendship, says Groopman, is that special bond between a doctor and his patient.