Humans are indeed a unique species in that we have the ability to condition and recondition ourselves. Our response to any given stimulus is influenced primarily by four “endowments that make us uniquely human” (70).

• Self-awareness
  • Thinking about your very thought process
• Imagination
  • Creating in our minds
• Conscience
  • Having an inherent idea of right and wrong
• Independent will
  • Acting on our own self-awareness

Dr. Covey makes repeated references to the “social mirror”, or the perception of ourselves which is dictated by outsiders. If left unchecked, these perceptions (known as paradigms) will impede the strengthening of our proactive lifestyles and possibly force us towards reactive responses. Whereas proactive people take the initiative to choose how to respond to certain stimuli, reactive individuals are highly influenced by their environments and other outside factors.

According to Dr. Covey, one of the best ways to examine the our self-awareness is by thinking about all the things which concern us, and among them, those which we actually have an influence over. Being proactive empowers people to expand their “circle of influence” and better deal with direct control, indirect control, and no control problems.

There are some people who interpret “proactive” to be mean pushy, aggressive, or insensitive; but that isn’t the case at all. Proactive people aren’t pushy. They’re smart, they’re value driven, they read reality, and they know what’s needed.

I think naturally, I tend to be pretty proactive about all parts of my life; however, I’m also guilty of the “If only I had…” syndrome. The problem isn’t out there; therefore, I have to address it within me. Maintaining the “inside-out” way of thinking is a must.

The introduction offers a comparison between the Character Ethic and Personality Ethic. The former, which has unfortunately been pushed to the backseat in our modern society, focuses on principles inherent to all humans – honesty, integrity, intelligence, etc. The latter dwells mainly on how we adjust our personas to become exactly what society needs us to be. We change ourselves to be liked by others… to assimilate… or just to feel different.

Next, the author teaches us to live from the inside-out. As responsible individuals, it becomes a necessity to focus on how we can change ourselves rather than projecting the source of our problems on others.

Finally, Dr. Covey describes the P/PC (production/production capacity) ratio using the classic story of the goose that laid one golden egg per day. The greedy farmer wanted more golden eggs (P) faster, so he kills the goose in the hope of finding many eggs inside of it. He finds nothing. Now, not only has he eliminated his production capacity (PC), the goose, but entirely doomed his production (P). This lesson outlines the importance of nourishing your source (PC) to ensure a stable (P). One must also understand the delicate balance between the two factors.

For example, most students get an education (PC) to ultimately have a secure, well-paying job (P); however, if the student spends his/her entire life in education earning degree after degree without applying it to a career, (in other words, PC >> P), their maximum potential will never be attained. Likewise in the golden egg story where P >> PC, the demise of the goose (PC) ultimately leads to the demise of the golden egg supply (P).

Mahatma Ghandi once said:

“Be the change you want to see in the world.”

As individuals aspiring to achieve the highest level of success, we have to find it within ourselves to create change. Whether it’s in marriage, friendship, or business relationships, we have to focus on the Character Ethic, harnessing the principles of integrity, honesty, etc. to drive us onto the proper path.

The Epilogue and Afterword chapters outline a series of questions you should discuss with your doctor to provide you and the physician with a better understanding of the problem at hand. The road to formulating an accurate diagnosis is lined with many paths of cognitive error, but by asking these questions, you can ensure that the physician avoids committing such errors and you become more informed about the condition:

• “What else can it be?”
  • This will prompt the doctor to pause, think again, and extricate himself from a cognitive trap.
• Could two things be going on to explain my problem?
  • Occam’s razor (“the simplest explanation is usually the best one”) is something medical students are indirectly thought to believe, and in most cases, this is the case; however, by asking this question, you force the physician to address the pitfall of “satisfaction of search” where the first diagnosis becomes the working diagnosis without ever evaluating other possibilities.
• “Is there anything in my history or physical examination or lab tests that seems to be at odds with the working diagnosis?” 
  • This will safeguard against “confirmation bias.” Confirmation bias occurs after the physician has an initial diagnosis. Any symptoms which do not coincide with this initial diagnosis will simply be brushed off as irrelevant rather than being further investigated.

All in all, How Doctors Think was a fantastic book that I’m glad I read before starting medical school. Next I’ll be reading Complications by Dr. Atul Gawande which was a gift kindly given to me by Oscar.

Though a surgeon’s hands are traditionally regarded as his greatest asset, it really is his framework of thinking which is the most pivotal. Sure, manual dexterity comes in handy to suture tiny blood vessels, for example, but in the grand scheme of things, it’s the calm and structured thinking which always governs successful surgeries. In fact, each of the surgeons the author visited had lost sight of this mentality and ultimately committed an error. It wasn’t until the fourth one (who happened to be the youngest) till a successful diagnosis and treatment was reached.

Just like the first surgeons (labeled ‘A’, ‘B’, and ‘C’), surgeon D examined the images of the author’s hand/wrist; however, rather than disregarding aberrations which seemed irrelevant to the painful condition, he tried to unify the symptoms into a collective theory which proved to be correct. He concluded that since the pain presented during motion, more images needed when the wrist was contorted. The new images revealed the underlying problem, and that was that.

So where was the oversight from the previous surgeons? Well, in this case, precedent was harmful. If physicians are so preoccupied with relating a new patient’s case with something they recently saw, they may entirely miss the proper diagnosis. Furthermore, it’s dangerous to label certain symptoms as “coincidences” or “meaningless” just because they differ from the previous case.

I’m about 70-80 pages ahead of this chapter right now, so I apologize for the lack of detail.

Let’s say you’re a neurosurgeon thirty years into your practice. You’ve seen everything ranging from relatively simple disc herniations to painful trigeminal neuralgias and even elusive brain stem tumors. More often than not, your patients have been referred to you by another doctor, and with your years of expertise, the proper diagnosis is almost always made and relevant surgery(s) is performed.

Now let’s say that your friend sees a barrage of less specialized cases working in family medicine. Patients come in with abdominal pain, headaches, sore throats, etc. These symptoms are far more open-ended, and while Bayesian analysis is frequently utilized for the diagnosis (ie, if a patient presents with a sore throat and fever, he or she is way more likely to have strep throat than anything else), it’s more likely that the doctor could overlook something more serious.

After all, if a patient has blurred vision and brain imaging reveals a tumor pressing on his optic chiasma, a causal relationship between the tumor and poor vision can be established with near certainty. If a patient has a pain in his gut, there are tens of worthy diagnoses which could fit the symptom. If a physician doesn’t keep an open mind in the differential stages, he or she could tumble down a slippery slope of mistakes.

There’s a particular statement at the end of chapter two which concisely yet directly addresses what I’ve learned so far.

Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents.

Doctors may like any given patient for any given reason. By the same token, doctors may be perturbed by a chain smoker coming in for meds to take the edge off his/her end-stage emphysema. Does this mean that doctors should focus more on the technical perspective of medicine rather than the emotional aspect? Of course not. Without a sound relationship between a physician and the patient, many critical components to an accurate diagnosis may be entirely missed.

As a future physician, it’s important to understand that emotional attachment can be dangerous. For example, if I really like a particular patient, I’ll subconsciously try to avoid the possibility of proclaiming a terminal diagnosis. After years of relating to the patient and having him confide in me, would I really want to explore the possibility that the stomach pains he presented with could be more than simple indigestion? At this point, I know very little about “real” medicine, so it’s easy for me to think that I’ll never fall for such a trap. I’d like to think that I can keep my technical skills separate from my emotions, but I foresee the gap closing once I get thrown into the medical environment and have to treat real patients with real diseases.

Being mindful of emotions seems like a relatively trivial concept, but reading about great doctors succumbing to their feelings only to realize that many of their patients died due to a simple oversight is a bit eye-opening.

My journey began yesterday at the Barnes and Noble in First Colony. While my mom was shopping at some of the retail stores in the mall, I browsed through the “Computer Programming” and “Medicine” sections hoping I’d come across something which would inspire me to finally pick up a book and complete it. I was greeted by several “New York Times Best Seller” novels which made it even more difficult to pick; however, based on my pre-med status, I decided that I should avoid books dealing directly with the knowledge aspect of medicine and focus more on the abstract topics. Dr. Jerome Groopman’s How Doctors Think struck me as the perfect choice.

So starting today, I’ll regularly post what I’ve come across in the book. Stay tuned (and wish me luck in actually completing it!)