How Doctors Think, by Jerome Groopman, M.D.

A terrific book. Groopman takes on the task of figuring out how doctors make decisions about treatment. He finds that the majority of medical mistakes come from certain types of thinking patterns that doctors fall into. He offers simple suggestions to both doctor and patient to help the doctors break out of these patterns in particular cases.

Patients and doctors can benefit most by understanding the "three As", as they were termed by one reader:

• anchoring

• attribution

• availability

"Anchoring" is seizing on a set of symptoms, making a snap diagnosis and not looking further

"Attribution" is making assumptions about a patient because of certain patient attributes - old, young, complainer, whatever. In an episode of House the patient was a hugely obese man who insisted that the doctors look past his weight for what was wrong with him. Turns out he was right; the diagnosis was bad but had nothing to do with his weight.

"Availability" is the tendency to remember, in a flash, similar cases and assign the present case to the same group. For example, if the doctor has been treating a number of people with abdominal pains and they all had acid reflux he might jump to that assumption in a similar case because the diagnosis is "available" - frequently used, easy to call on.

I am sure I haven't described these as well as I could. What is critical for patients is to ask some meaningful questions when they feel the diagnosis may not be right for some reason. Here are the questions Dr. Groopman suggests:

"What else could it be?" - this question can break the physician away from a snap diagnosis.

"Could two things be going on at once?" In other words, might there be two problems instead of one?

"Is there anything in my history or the tests that seem to be at odds with the diagnosis?" Sometimes doctors see symptoms that "don't fit" but simply label them "atypical". This question brings those symptoms to the front.

I want to give a copy of this book to the doctor I have seen a few times, the doctor I am starting to consider my primary physician. I think all doctors should read it, and in the case of my doctor I suspect he actually would. It's a great resource, written compassionately and clearly, that does not condemn doctors; instead it can help them be better than they are.

The Glass Castle, by Jeannette Walls

A memoir about a family living on the edge, deliberately.

Walls is born to parents who are highly intelligent and creative but whose own presumably (and suggested) dark pasts make them both junkies for excitement and change. Thus they live from hand to mouth, rarely staying in one place longer than a couple of months, for the early part of Jeanette's childhood. Jeanette's father is an alcoholic who isn't able to keep a job but who has big dreams as well as big smarts. He manages to keep their various vehicles alive one way or another, devises engineering feats where necessary, teaches his children about the stars, about physics, about math, proudly pushes them (literally) into the water where they must sink or swim.

Her mother wraps herself into her own creative ventures, painting, writing, sketching, and is usually ready when the family has to "skedaddle" in the middle of the night. Neither parent worries about the health of their children, living by the maxim that what doesn't kill you makes you stronger. On this front it appears that her mother is the tougher of the two in some respects.

By the time Jeanette and her family move into Welch, Virginia, her father's childhood home, she certainly can take care of herself. She worships her father yet recognizes that he has failed her time and again. All of the children - Lori, Jeanette, Brian, and Maureen - somehow manage to find food, stay clothed, and go to school, and even excel. They don't make friends easily, finding that even in this "okie" territory they are outcasts, dirtier, skinnier, and tougher than the rest.

It's a memoir of a tough life that at times seemed wondrous to Jeanette. Being given a star for her birthday. Sleeping in a cardboard appliance box. Being encouraged to challenge life rather than be challenged by it. Thus it is more than a sad tale of children of an alcoholic, even though those of us who share that distinction are going to recognize some of the responses. It is more a tale of resilience and hope and ultimately simply acceptance.

Black Dahlia Avenger, by Steven Hodel

I confess to a perhaps unnatural fascination with "true crime" stories. I have read many, from the very good to the unbelievably bad. But that isn't the primary reason I wanted to read this book.

When I visited a special motel in Desert Hot Springs one year the owner told me that Steve Hodel had been there and had told him his story about the Black Dahlia (Elizabeth Short) murder. The motel owner (a friend of mine) was highly enthusiastic about Hodel and his book. I decided to get it some day, in large part because of that endorsement. That day came when I saw that it was available through paperbackswap.

Hodel is a retired detective from the same police force that investigated this murder years before he joined. His experience as a detective led me to believe that his research and analysis would be sober, thorough, and logical, even though it focused on his father.

It's a thick book, full of details and exhibits and what the author refers to as "thoughtprints" - his way of connecting dots. His use of these thoughtprints bothered me a bit because they are a way of relying on assumptions more than on cold hard evidence. I recognize that the type evidence he obtained was not direct (photographs, memories, notes with odd references, newspaper articles) and it was necessary to try to piece together the meaning from them, but I felt he went from finding this type evidence to drawing those conclusions and then referring to his conclusions as fact. It seemed odd that a detective would make such leaps.

From the beginning I wondered about his decision to do this investigation without aid of LAPD files on the subject. He made several assumptions about their availability but did not actually make the effort to obtain them until after the book was published (this version of the book is the expanded version and does include information from LAPD files). His explanations, that he no longer has the connections to the department that he once had, didn't convince me. In his place, if I had the other materials that he unearthed and so carefully labeled and reproduced, I would have been hungry for confirmation of my conclusions, hungry enough to see how far I could get in looking at those files.

Another block to my own ability to buy Hodel's story whole is the writing itself. I am sure the editors worked slavishly to make it readable and to organize it. Sometimes, though, you reach a point where you have to say "enough" and let it go out in the world. I suspect this is what happened. The book is repetitious, oddly organized, and difficult to wade through. It got to the point where I set it down after reading just a page or two, then picked it up later to continue slogging on. A better writer might have been able to put it together better and make a better case with the same facts.

Hodel may well be right in many of his assumptions, and the case he made for a "coverup" in the years surrounding the Black Dahlia murder and early investigation, is convincing. In fact, the case he makes against his own father as the murderer is worth serious consideration. I do quibble with some of his reasoning:

He draws a portrait of his father as a man who used women and then discarded them (except for his last wife, who hung in for 30 years). Yet when Steve Hodel creates a possible motive for the killing of Beth Short he assumes Short agreed to marry Hodel and when she later jilted him he became enraged and killed her. The two pictures of George Hodel don't match, in my opinion.

I also found Hodel's "evidence" that his father's longtime friend, Fred Sexton, also took part in some of the murders Hodel attributes to his father unconvincing. One part of the evidence is a photograph of Sexton compared to a police sketch of a perp seen by a witness. The drawing shows a man with a prominent widow's peak, while Sexton has none and has a high forehead. I can't buy that they are the same man.

All of which does not mean that I don't believe Hodel's basic conclusion that his father killed Elizabeth Short. It seems very possible and even likely. I am less convinced by what he trots out as the other murders also committed by his father.

I am frustrated that all his work did not lead to an official investigation, a circumstance that clearly befuddles Hodel as well. At one point he took his findings to a DA in Los Angeles county offices, a person who could in fact find reason to call for an investigation. The chapter is titled "Filing My Case with the District Attorney's Office". Yet he did not officially file the case there. Instead, he contacted a member of the office whom he knew, gave him the information, and requested an "as-if" memo. The DA knocked out a several-page memo stating that he would file it if it were real. Why didn't he file it for real? I didn't get a good answer to that either.

A near-exhausting hunt that, for me, turned up almost as many questions as answers.

Predictably Irrational, by Dan Ariely

I think by now we all know people act irrationally, especially given the recent spate of books using research from the new field of behavioral economics. Many of us despair of ever making a dent in other people's beliefs by use of rational argument backed up with solid evidence. Even highly intelligent persons will review the reasoning and nevertheless jump to this position: I see the evidence and I still don't believe it.

Ariely sets out to confirm, through well-designed yet simple experiments, that we do in fact behave irrationally. What he finds, however, is that we are irrational in the same way when faced with the same choices: we are consistently, predictably irrational. And there is hope in this.

For example, when faced with three choices of DVD players on sale, ranging in price from low to high, we will predictably choose the middle one. This because the other two have set "anchors" for us. Knowing this, we can see how salespeople can manipulate us to make the choice they want us to make. Knowing this, we can go to the store armed with unbiased research and choose the model we actually want and ignore the manipulation. Knowledge is indeed power.

But that doesn't mean we will be able to escape our inner irrationality every time. Even Ariely admits to being caught up in a choice between equals that cost him time and money and didn't lead to a better decision. In cases like his it is good to step back and look at the consequences of either decision and then just get on with it. When there isn't much difference between them why agonize - just choose.

Many of the research experiments were designed to ferret out basic human inclinations. In some cases there are factors that can make a big difference, however, that may make the real situation lead to different results in some people. For example, Ariely offers the example of his wife when she was pregnant. She wanted to have a drug-free birth. To determine if she was up for the ordeal, the birth coach suggested that she simulate the pain by putting her hand in ice water for a certain period of time. If she could handle it, then she should feel good about her decision to avoid drugs. She felt she could not handle it and therefore was persuaded to have an epidural when the time came. I believe there are factors that influence such decisions that have little to do with how much pain we can handle. My own experience differs in a significant way from that of Dan's wife and not because I have a high pain threshold:

When I was pregnant I too determined that I would have a drug-free birth. I prepared for it by attending Lamaze classes and having a coach with me during labor. Although the pain was intense, far greater than I had anticipated, and although it went on for a long time, it never occurred to me to ask for pain relief (beyond the breathing exercises). The reason is twofold: 1) I knew drugs would get into the baby and would affect the experience negatively for both of us; 2) I knew labor has an end point. I would not be in pain forever. This knowledge kept me strong throughout and I successfully delivered both of my children without drugs.

However, if I had a severe migraine headache I would take relief in a second, even a painkiller I knew was not good for me in the long run. I would seek any kind of relief. Others have said that when in the grip of a bad migraine headache we just want someone to shoot us. In that case taking a drug affects only me and if I don't take it there may not be an end to the headache for a very long time. Different circumstances indeed. I don't think simulating labor the way Ariely's wife did was an accurate way to simulate the entire experience - even though in her case she did opt for an epidural. My point is that sometimes we have knowledge that changes the experience for us in the individual case.

I do believe the experiments Ariely and friends undertook offer great insights. And we should pay attention to the results, even while we may find that we have some variations in our own responses to similar circumstances.

Another objection I had to the book was with the recommendations Ariely made at the end of each chapter. He would sum up the type of irrational behavior and then offer ways we can overcome our own irrational tendencies in similar circumstances. The recommendations are weak and general and left me feeling a bit lost. I almost felt it would have been better if he'd offered no recommendations at all.

Of particular usefulness should be the chapters on "Free!" and the use of placebos in studies. Reading these chapters should make us aware of why we tend to choose more expensive medical treatment (even when identical to or even worse than the cheaper version) and why free stuff isn't necessarily free. Understanding these concepts could make major differences in our lives and our spending.

Better, by Atul Gawande

In this book Gawande focuses on performance: how well doctors do what they do.

He finds a few who step out from the rest, who are in effect "rogues" because they won't settle for "standard practice". Especially representing this group is a doctor who works on patients with cystic fibrosis. He invented a special jacket these patients can wear that pounds their chests (using air) to loosen mucus inside (previously patients had to depend on family and friends to pound their chests for them). He also insists on higher levels of performance from his patients and asks them directly what they have noticed about their illness, as a way to developing more specific care for them. The proof is in the result: his patients live far longer than average cystic fibrosis patients.

Through each of the little stories in this book Gawande looks at results. Instead of peering into a microscope to look at causes of illnesses he looks at how doctors get results. And he concludes that medical miracles are not the answer; rather, doctors using what they have at their disposal and using it well will get better results.

I had some quarrels with some of his conclusions but I could not fault his reasoning. For example, he compares the use of forceps in difficult deliveries to the use of ceasarean section. A C-section is easier to learn and perform for all doctors and therefore can more reliably be used than forceps, which require special skill to use correctly. He hints at the overuse of C-sections but does not challenge current medical practice enough for my satisfaction. But I can't argue with his conclusion that if our goal is to achieve more healthy live babies the increased use of C-section may be the correct route (personally I think less interference is better, that proper vaginal deliveries are preferable and especially without drugs, but this route requires greater understanding of the process and a willingness to let nature lead). He does note that nobody is keeping track of the condition of the mother, however, and that this is a focus that needs to be changed.

I also wondered about his conclusion that increased use of mammography is where it's at in breast cancer - many studies have concluded that mammography is only helpful in specific older age groups and that in others it is a waste of resources. However, his real emphasis is on a bigger question: how do you change a population's habits for the better? (In the case of mammograms the massive public information blitz changed women's habits and led to greater numbers of mammograms being done.) It's a question that needs answers.

The book provides great insight into the medical profession and where it is headed. It's thoughtfully and compassionately written by a surgeon who pays attention and takes notes. The afterword offers five actions a doctor can take to become a "positive deviant" - a doctor who achieves better results. It may be surprising to discover that Gawande, as much as he admires the stand-out rogues, is trying instead to reach the majority of doctors, to encourage them to use what they have better rather than to reach for unattainable stars.

Freakonomics, by Steven Levitt and Stephen Dubner

Levitt and Dubner repeatedly say that this book does not have a "theme". And in the sense that Blink or The Tipping Point have themes, they are right. But it does have a fundamental focus: on "conventional wisdom".

Levitt, as an economist, has made his name by asking different questions - like "do teachers cheat?" - and by finding ways to sort data to get the answers he is looking for. Dubner interviewed Levitt for a NYT article a while back and soon a collaboration was born - the collaboration that yielded this book. Both Levitt and Dubner appear to be good writers, as evidenced by the Freakonomics blog at http://freakonomics.blogs.nytimes.com/, where both post individual as well as joint articles. I sense that the overall style of the book is more Dubner than Levitt, based on my seeing Dubner speak at Prosper Days (see my articles on Prosper Days at http://fightdebt.blogspot.com/search/label/Prosper%20Days).

In this book we find answers to a wide range of questions that few people would think to ask, about topics from sumo wrestlers to parenting. What does it have to do with economics? Simply that it has to do with how people get what they want - and how people can be encouraged to do the right thing and avoid doing the wrong thing. The outline of the entire book can be found in Dubner's original article, which is included as part of the additional material in this book, along with selected blog posts and heavy-duty footnotes.

I for one really did want a bit more of a theme than this non-theme, but I do think the basic premise is sound and a good reason for people to read the book - it is important to question conventional wisdom. For example, at one point another economist read Levitt's original article on the relationship between abortion and the drop in crime, and he said (I'm paraphrasing), "I have read this over and over and I can't find anything wrong with it, but I still don't believe it.". This is how most of us are: we can be faced with incontrovertible evidence but we find it difficult to let go of what we have believed for so long.

Overdosed America: The Broken Promise of American Medicine, by John Abramson

You may have suspected it. In spite of the incredible expense poured into our health care system we aren't any healthier. Here, then, is the proof confirming your suspicions and the why.

Near the end of the book Abramson, a long-time family doctor who has an extensive background in statistics, epidemiology, and health policy, puts it simply: the bad news is that many of our celebrated advances in medicine, including new drugs, medical procedures, and sophisticated equipment, do not perform as well as older treatments and cost a great deal more. The good news is the same! If we knew what really works, based on unbiased well-designed studies, we would not need to use expensive treatments, equipment, or drugs nearly as often as we do, and we'd be better for it. In other words, our health care costs would drop and our health would improve.

Our health care system has gone so far astray that in comparisons with other developed countries the U.S. pays twice as much for abysmal results. And it really is not an accident. And it isn't because we eat too much fried food (although, of course, we do have to take responsibility for choices within our power). Read this book and find out for yourself. It's easy to read, clearly written, easy to understand. And so important. I would like every one of our political leaders to have a copy.