What Doctors Think

A number of years ago, Dr. Jerome Groopman published a wonderful book for the benefit of patients and their physicians, entitled How Doctors Think. It is an excellent description, illustrated by anecdotes, of the cognitive processes by which doctors arrive at diagnoses, and the pitfalls that are inherent in such calculations owing to the inherent strengths and weaknesses of human thought processes. For example, our tendency to consider conditions that we have seen recently, or those for which can easily imagine examples, is one habit discussed in some depth. It is a fascinating read (or in my case, listen, as I heard it on a CD in my car over the course of a couple of weeks.)

So Dr. Groopman has exposed well how doctors think. But how often do we reveal just what we are thinking? No more often, in my opinion, than we reveal our inner thoughts to friends and relatives in our personal lives – and in fact, considerably less often if we value our professional success. We occasionally let slip our attitudes in a moment of carelessness, a gesture, or the infrequent loss of temper. But for the most part, we try to embody the ideal of “equanimitas” that was advocated by one of our icons of modern medicine, the great doctor William Osler. There have been many learned treatises on this quality as to its benefits to a physician and his patients, and I have little of great insight to add on that topic.

But wouldn’t it be nice to occasionally allow ourselves to express what we really think?  I always enjoy arriving home  – usually somewhat later than I promised – to relate some of the triumphs and tragedies of the battles of the day. And this, of course, is when I get to say what I really think. It has occurred to me that I might even collect enough material to publish my own book, What Doctors Think.

My wife suggested an alternative or a sequel entitled Do Doctors Think?

I am choosing to ignore the suggestion for the purposes of this post.

I recently receive a letter from another specialist I had occasion to consult. It was an excellent evaluation, clearly dictated, and in a style not yet of the computer-generated boilerplate type that is becoming commonplace now that the electronic medical record is taking hold.

It began with a “thank you” for the referral, a glowing description of the “delightful” character of the patient, and ended with another expression of gratitude for the opportunity to assist in her care. In other words, the same sort of letter I always send to my referring physicians. It struck me, as it always has, how stereotyped these phrases are, so that they, too are really just insincere pleasantries. I am especially amused when I know full well that my patient is anything but delightful and his next visit with my consulting physician will not likely be greeted with delight. The fact is, we all need to be stroked, and being commended for sending a patient will very much increase the likelihood that I will send another. Of course the converse is true. It led me to wonder what sort of letter I might write if I truly expressed my opinion.

So during a tedious session at my laptop during a weekend getaway marred by bad weather, I found my mind wandering from the editing of office notes and reviewing of labs I was doing remotely. In a moment of malicious glee, I started to compose the following consultation note as a parody of everything I have ever been tempted to dash off to my referring physicians. It soon finished itself. For the non-physician readership, please be advised that the following does not represent the actual views and attitudes  of the writer, the American College of Gastroenterology, the various institutions that will disavow any connection with me, or those of the medical profession in general.

Dear Jerome,

I am not sure how to  thank you for asking this most unpleasant gentleman to see me for colorectal cancer screening. So I won’t.

Although the patient appears to be entirely well, he offers a litany of gastintestinal complaints that might not have occupied me for the better part of an hour had he not had an unfortunate tendency to veer of onto other concerns both political, economic and pertaining to the general state of mankind , not to mention the unfair manner in which the world has treated him personally.   Even after returning to the topic of his GI tract, I was unable to determine whether he was magnifying the  severity of his symptoms, except in regard to his complaint of excessive flatulence, which became more and more verifiable as our interview proceeded.

The past medical history was obtained with some difficulty, the patient insisting that there was nothing really wrong with him and all of his current diagnoses had been made up by the 6 or 7 previous physicians who had attended him, none of whom was fit to care for his cat.

His medication list  consists exclusively of herbal and natural remedies that he is prescribed by his chiropractor, naturopath, personal trainer and his reiki therapist. He insists that they have done him more good than that penicillin some quack he recently saw had wanted to give him for some imaginary condition, that he thinks was called “STD”.

He reports having had allergic reactions to cortisone, prednisone, benadryl and all foods that begin with the letter “R”. He is intolerant but not allergic to foods that conclude with the letter “L”.

He has a 40 pack-year smoking history which he incurred during his 2-year stint in the Congolese mercenary army; he no longer smokes. He proudly informs me that his alcohol intake has recently diminished to only two 6-packs of beer a day at the advice of his naturopath, who has sold him an amazing product that when consumed at 3 quarts daily has had a miraculously salutory effect on diminishing his capacity for beer.

The surgical history includes traumatic amputation of the right 3rd digit in a barroom accident, multiple fractures of the lower extremities, and a circumcision that occurred in the course of his 9th and most recent sexual relationship.

The family history is largely unavailable, as he is estranged from his parents, his siblings, his children, and a large number of people who only vaguely remind him of other family members.

The social history is significant. Although the patient stated he was unemployed and unmarried on our intake form, he was accompanied in the exam room by two young women who appeared to be under the age of 16. Also noteworthy is that he has no insurance and insisted on paying in cash, but only after inspecting our waiting room and my exam room as if he was looking for something.

Physical Examination:

The vital signs were unremarkable except that we were unable to weigh the patient due to his inability to balance himself on the scale.

He is a somewhat easily distracted gentleman in no acute distress who was found looking through the supply drawers when I entered. He appeared resentful and malodorous. He is wearing an exam gown over his clothes.

HEENT: Muddy sclerae and muddy cap with logo “I’m with stupid”.

Neck: Unable to find

Chest: Dullness with diminished breath sounds due to increased soft tissue. When asked to inhale he had to be reminded to exhale as well.

Heart: Sounds obscured by scratchy noises from hair on chest during respiration and patient insisting on speaking during exam

Abdomen: Upon lifting pannus it revealed a bottle cap and  a large cast brass belt buckle showing a pair of young female silhouettes back to back.

Genito-urinary: deferred and denied

Extremities: Tattoos on the extensor surfaces of proximal phalanges spelling “Joann” on the left hand and “Tr_sh” on the right. (missing letter and finger; patient says it was an “i”). I decided against having him remove his boots.

Skin: Multiple tattoos some of which appeared to have been professionally done but distorted by body habitus.

Neurologic: Sluggish pupils and sluggish in general. Startled easily by ring-tone on his phone despite 3 signs in room asking patients to place their phones on vibrate.


This gentleman has attained the age of 50 years in spite of multiple risk factors for death by tobacco, alcohol, firearms and trauma, and one might argue that having navigated circumstances that would have put a period to a less fortunate soul, he can only be described as “lucky” and therefore in need of no preventive measures. Guidelines do, however, call for colorectal cancer screening  at his age. On the other hand, one might also argue that the patient’s pre-test probability of demise in the next 10 years is great enought that his post-test probability would not be significantly affected by cancer prevention. On the other hand, if I recommend against doing a colonoscopy, I am sure you will refer him to some other gastroenterologist who will  be happy to do one. Thus, the benefits for me of the procedure greatly outweigh the risks to me. I am not greatly worried about the patient’s risk, as it is well known that God protects children, drunkards and fools.


I have discussed the rationale for colorectal cancer screening and the benefits, alternatives, techniques and risks of colonoscopy in detail, including but not limited to bleeding, infection, perforation, surgery, colostomy, stroke with temporary or permanent loss of function, heart attack, death, aspiration pneumonia, drug allergy, phlebitis, motor vehicular accident due to absconding after the procedure having falsely claimed to have a ride home,  need to reschedule as a result of factors such as failure to follow prep instructions with inadequate prep, blizzard, hurricane, earthquake, other acts of God, spontaneous combustion, and The Rapture. The patient had an adequate opportunity to ask questions. His only inquiry was, “I’m not going to know nothin’, Doc, RIGHT!?” Accordingly, a procedure has been arranged.

I can only hope that the next patient you send this way will offer me the  honor and a privilege of participating in the care of a somewhat more pleasant gentleman.


David M. Sack, MD

I can’t wait to hear back from my referring physicians what they really think of my consultation notes!

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

18 replies »

  1. Howdy! This is my 1st comment here so I just wanted to
    give a quick shout out and say I really enjoy
    reading your blog posts. Can you recommend any other blogs/websites/forums that
    go over the same subjects? Thank you!

  2. Gee, you have to ask who gets to define what a poor choice is? Has common sense and decades of medical observation been dumbed down to just trust whatever some doofus writes at a site on the internet?

    Yeah, let’s debate tobacco, alcohol and substance abuse/dependence, poor dietary choice, sedentary life styles as those are elements that have strong defenders to legitimize their presence in lifestyle choice.

    Start with the core offenders and get boundaries and consequences put into motion. Debate the softer matters later.

  3. There are plenty consequences for poor choices: getting sick, being in pain, losing limbs, vision, mobility, dieing early, being miserable, lonely, broke, homeless, jailed…… Do you think your $50 fine would be scarier?

    And who gets to define what a poor choice is? The government? The Church? The corporations? The citizens committee on moral hygiene? You?

  4. So, are you in the 80% bracket or the 20% one?

    Why can’t we as a society expect people to make responsible, healthy choices on a consistent basis and have the right to challenge those who choose otherwise? Being politically correct is an incorrect attitude.

    Sorry, I see nothing that demands me to look the other way when someone walks into the office and has a lifetime of poor choices and then expects me to make a full court press to continue their existence, most likely to continue making poor choices, as behaviors do not change for the better overnight. Especially when there are no real consequences for poor choices. Getting the best care for the worst attitudes is just wrong.

    Now there is another category in America: “terminal hope and faith in all”.

    Or, how about “self destructive naivete”?!

  5. I think this humurous post brings up real problem: the fact that aspects of patient centered medicine and consumerism limit physicians’ abilities to express a neutral professional opinion, at least re. the aspects that might (or may be interpreted as to) reflect negatively on the patient. I recently saw a patient who spent most of the encounter time talking about issues completely unrelated to the condition/chielf complaint, and there were multiple statements and historical details that made me think that the patient might have a (narcissistic) personality disorder. I indicated that very briefly in the lengthy referral letter, clearly as a consideration (I am not a psychiatrist), not as a fact or stated diagnosis. The patient apparently obtained and reviewed the note and took offense at the (entirely neutral, factual) description of the encounter and the consideration of a personality disorder and wrote an official complaint to patient relations, resulting in various Emails, official responses etc.

    Unfortunately, there are multiple facts and suspicions that are (or can be felt to be) unpleasant to/by the patient: drug abuse, family conflict, malingering, psychogenicity/somatization and psychiatric disease (even though it should not be stigmatized, but it is) etc. – other doctors may or may not agree with the assessment/suspicion, but bringing these issues to the attention of the referring physician’s attention is ultimately in the patient’s best interest.

  6. That’s actually funny, and resembles My People. (I grew up in appalachia.)

    I’m glad to hear that the free-form Shakespearean notes the doctors are defending — against the computer “boilerplate” — are actually widely known to be “insincere pleasantries.” After a lifetime watching this flow of ex tempore text among physicians, I’ve concluded very little of it can not be templated, and the resistance is just injured ego. What do you mean I can’t describe what I think with words of my own choosing? The world needs it!

    No, actually no-one reads it.

  7. Did you find the consult note funny, Dr. D? I thought it was hilarious.

    Without guys like this fictional, but all too real, patient, there can be no funny stories. There can be no sad stories. There can be no tragedy and no triumph.There can be no stories at all. Only standard issue people, marching dutifully to their colonoscopies, vice free, alcohol free, tobacco free, fat free, taste free, humor free, surprise free, life free.
    What would the world be like, I wonder, if we had no sins, no vices and if we made no mistakes… Maybe we would live forever, or at least it would seem so, before we die from sheer boredom.

    We’ll figure out the percentages somehow, and the considerations and the money (which is not a resource 🙂 ). Maybe there will be pain and tragedy along the way, maybe not, but I have no desire to extinguish the essence of life just so everybody gets a colonoscopy.

  8. Dr. Sack strategically omits the third party payor info on his patient. I guarantee it was not the patient.

  9. That’s some funny stuff, Doc.

    “I recently receive a letter from another specialist I had occasion to consult. It was an excellent evaluation, clearly dictated, and in a style not yet of the computer-generated boilerplate type that is becoming commonplace now that the electronic medical record is taking hold.”

    Ouch. You’re talkin’ about my job!


    I have Dr. Groopman’s books, and I cited him here recently:


    Y’know, cops tend to come to view all people as Perps. And, then, of course, there are the totemic Caddy Driving Lobster Eating Welfare Queens.

    Undeniably, there is a distribution of personal character unpleasantness (and DeterminedMD would no doubt rank me very, very high, though we ARE trying to Make Nice. I’m not gonna crack on him any more).

    The relative prevalence of your exemplar, though, is — however imprecisely — an empirical matter (i.e., the lifestyle dysfunctional, non-compliant, Tragic Script patient **). But, as Simon Blackburn notes (paraphrasing), we gotta have Our Stories.

    (Axiom 101 for trial lawyers: He With The Best Story WINS.)

    None of which is to dismiss your observation. I hear lots of equally cynical shop talk in the course of my work.

    ** I have a Munchausen case story for you, a pt I tracked via Medicare MedPro claims data in the early ’90’s. It was unreal.

  10. Best post I have read here in my travels thus far. I wrote a fairly detailed comment that this damn server I have to use tonight outside my home lost, another reason to distrust the internet as a whole for such inconsistency, but will just keep it short in rewrite.

    Want to really responsibly and effectively work on controlling costs and maximizing the limited resources that exist in health care (yes, a shot at you, Ms G-A for your insistence on a different reality than the rest of us)? It is time to stop the full court press for terminal addicts who have no interest in accepting recovery, and the elderly who’s main reason for prolonged care is most often driven by family members not fully committed to expending their own costs of time, energy, and money in doing their share in providing for their diminishing person as patient. And, for ALL of us, it is about accepting the role of preventative interventions to minimize illness as best we as providers can ascertain will run the risk of developing maladies/disease.

    Simply put, goodbye to tobacco, alcohol and substance abuse/dependence, poor dietary choices, and avoidance of reasonable and fair activity levels as a start. You live irresponsibly and make poor choices, deal with the consequences. We’ll look and consider the exceptions case by case, but I live by the basic premise of 80/20. 80% of us know the risk/benefit profile and need to accept the terms of going outside the box. Stop acting like everyone is in the 20% section and deserves absolute understanding and consideration.

    Yeah, like that is going to happen!!!

  11. As for me I try to seek beauty and goodness in all my patients recognizing full well that this is a lifelong challenge. But it is a worthwhile goal with all of our human interactions- not just patients.

    I draw the line when the patient’s own self destructiveness could take me down with him/her. I do not believe in physician-martyrs.

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