Related topics: •  Book Review: AIDS Doctors

Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine
By Jerome Groopman, M.D.
Viking Press
234 pp $24.95

The scene opens in a hospital emergency room. An exhausted resident, anxious to get some sleep, assures the new parents that surgery for their son's intestinal blockage could wait until morning. But sensing the child's rapid decline and questioning the resident's competence, the couple decides to seek a second opinion.

This story, told by Dr. Jerome Groopman in Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine, is his own. It details his son's brush with death. During the torturous moments waiting for their son Steve's surgery, Groopman and his wife Pam, also a doctor, wonder if they made the right decision.

"I sat next to Pam in silence and closed my eyes. A series of flickering images appeared, like those from silent films. Steve dead, his lifeless form in a closed, rectangular pine coffin. But I could see inside. He was clothed in a white shroud, according to traditional Jewish custom. I then watched the coffin lowered into the moist ground in an overcrowded cemetery in Queens, next to my father. Dirt was shoveled over the coffin. Then the drab Waltham home, mirrors covered, Pam and I seated on low stools, clothes rent -- shiva -- the mourning of our firstborn son."

But this decision to seek another opinion, based largely on intuition rather than medical expertise, saves their son's life. Groopman tells this story while on teaching rounds with new doctors-in-training to remind these young physicians of their fallibility and its potentially fatal consequences.

In eight moving clinical histories, Groopman illustrates how important it is to evaluate -- and occasionally reevaluate -- one's medical options, emphasizing the merit of second opinions and the patient's intuitive responses to care. With this second book of medicine (the first was his 1997 book, The Measure of Our Days), Groopman continues to explore what he calls a physician's "clinical compass." It's the barometer built on a physician's medical expertise, as well as the intuition of both patient and doctor. These stories demonstrate what happens when the clinical compass correctly guides the doctor and patient through treatment, as well as the often-tragic results when the compass is absent or ignored.

A professor of medicine at Harvard University, chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston, and a leading cancer and AIDS researcher, Groopman believes that patients benefit most when doctors listen carefully to patients and tailor their treatment accordingly.

"In a predictable world, clinical decision making would be a well-defined, scientific exercise with set methods for diagnosis and treatment," Groopman writes. "The unfortunate truth is that this is not possible. People adapt differently, physically and emotionally, to each illness and react in varying ways to a given therapy. This means that diagnosis and treatment cannot be strictly bound by generic recipes, but must be made individual."

Clearly, Groopman doesn't always have answers. But he writes honestly of patients he has helped where there were no clear solutions and he was forced to follow -- in partnership with his patients -- his educated intuition. The intuition that goes into good medicine comes from careful listening, communication, trust, and time. Unfortunately, managed care is time's greatest enemy, he writes. "The least available element in the new world of medicine (is time). Managed care treats it as a tightly controlled commodity. Follow-up appointments with the doctor are often measured in single-digit minutes."

Another problem is conflict of interest. Observe the medical world as long as Groopman has, and you will see a world of colliding egos. When a physician challenges a colleague's opinion, hostilities may erupt. Groopman is no stranger to these skirmishes.

In the chapter called "A Routine Case of Asthma," a 36-year-old patient named Isabella Montero is diagnosed with asthma and gets a prescription for a Ventolin inhaler. Despite her continued shortness of breath, loss of vision in one eye, and weakness in her hand, no blood tests, chest x-rays, or cultures of her phlegm are conducted because her doctor claims that it is outside the clinical algorithm. But they discover later that instead of a routine case of asthma, Montero actually has acute leukemia, which ultimately kills her.

Groopman clearly believes managed care is only one obstacle to good care. Egos, ambitious research goals, and economic pressures may also influence physicians' decisions. Patients often fear offending their doctors with a decision to seek a second opinion, he contends, and it's a well-founded concern. Some doctors are threatened when patients seek second opinions, interpreting this as a lack of faith in their expertise. Patients may find it easier to trust in their first doctor's diagnosis rather than face contradictory opinions by two experts, Groopman says.

Reading "Second Opinions," Groopman's mission almost seems too good to be true. At times there is a subtle, self-congratulatory tone to his writing. Groopman is deservedly righteous about his opinions, but he acknowledges that his position is a privileged one. As a researcher, he faces none of the financial pressures created by insurance companies and by the constraints of managed care.

This part of the book, Groopman's crusade against the "malignant manifestation of money in medicine," may feel a bit shrill to some readers. But those who feel that the qualities often missing -- and most necessary -- in the practice of medicine are time, patience, and a good bedside manner will find something heartening in Groopman's message.

-- Siri Vaeth is a writer, social worker and former director of Big Brothers/Big Sisters of Santa Cruz County. She lives in Santa Cruz, California.

First published October 20, 2000
Last updated November 21, 2007
Copyright © 2000 Consumer Health Interactive