How doctors think

Edited by Kathryn Montgomery

Oxford: Oxford University Press, 2012

256 pp, Price £16.99 (pbk)

ISBN 978-0-19-994205-3

In this book, Kathleen Montgomery, an ethicist, elegantly explores the nature and importance of clinical judgement or ‘how doctors think’. For those inclined to dichotomise medicine as a science or an art, her answer is simple – medicine is neither and proponents of either view ignore the central, organizing role of ethics and all that medicine shares with moral reasoning. Medicine, she argues, is an interpretative practice, best captured by the concept of phronesis or practical reasoning. Circumventing a discussion about the nature of practical reasoning with its multiple personality in the philosophical literature, the author gives a simple description of the Aristotelian account of practical reasoning – the use of intellect and knowledge, the Aristotelian Sophia, to steer the best course for an individual patient in uncertain circumstances. Thus, clinical judgement is about ‘how’ knowledge is used by doctors rather than ‘what’ knowledge is used to achieve a desired outcome. There follows an interesting discussion on how the concept of phronesis clashes with Medicine’s need to portray itself as a science. In essence, phronesis does not involve a scientific ‘top down’ deductive approach but requires case-based reasoning. This involves the integration of different bodies of knowledge; the generalizable, reproducible scientific knowledge derived from populations; professional knowledge including values and experience of illness, and the patient’s story, to understand the complexity of illness in a particular individual at a particular point in time and to select the most appropriate management plan for that individual. Still, the value placed on science is so great that the interpretative skills required for phronesis continue to be learnt by stealth during medical training and remain unacknowledged in the subconscious of medical education. The fault for this cannot, however, be laid entirely at medicine’s door: both doctors and society collude to uphold Medicine as a science and this belief has its roots in the human need for certainty, the need to predict and control, in the face of chaos of illness. The costs are, however, great; patient dissatisfaction when expectations are not met and greater uncertainty for the clinician over the use of tacit professional knowledge in the interpretation of individual illness.

Readers of this book may be motivated, as I was, to question the nature of knowledge and wonder at how the use of scientific knowledge has become such a defining aspect of current clinical practice. The rise of evidence-based medicine and its implementation within health policy as ‘scientific bureaucratic medicine’, with its promise to rationalize medicine to the point of certainty, seems inexorable. Underpinning it all is the assumption that there exists a fixed or certain reality, that science provides the single best description of this reality (‘the truth’) and that biological organisms can be treated as physical, stable phenomena, the Cartesian res extensa, to be understood by objective measurements by the res cognitans. In actuality, Medicine’s position may be best described as a more subtle realism – a perspective that neither asserts nor denies the existence of a fixed reality but acknowledges the need to judge between different accounts with respect to how usefully that knowledge can be used to produce desired outcomes.

I have few criticisms of this book other than that. Surprisingly, given the emphasis placed on the limitations of generalizing over particularizing, the author unapologetically makes sweeping generalizations. ‘Medicine not only over-values science but has a limited interest in the particulars of the individual case, the patient’s experience’ she states. My years in General Practice belie this statement; patient-centredness is a core value of General Practice, and General Practitioners are adept at integrating biographical and biological accounts of illness and in recognizing the limitations of science in managing human distress. Thus, this book may have benefited from the inclusion of an analysis of the relative importance given to generalization and particularization across the various medical specialties and the tensions this may create.

Is this book relevant to those of us working in laboratory medicine? I think it should be essential reading, particularly for trainees. Robust training in scientific reasoning and cultural ‘result centredness’, together with the linear decision-making processes which predominate in the controlled environments of our laboratories, means that laboratory professionals, irrespective of background, may be more prone than most to applying Newtonian maxims to patient care and to failing to recognize the limitations of scientific knowledge in clinical decision making. This could be most problematic at the interface with the ‘swampy lowlands’ of primary care, where patients often present with undifferentiated illness. In this context, there is a low pre-test probability of disease and the focus is on interpreting illness in terms of human experience rather than statistically deviant biological metrics. Camus reminds us of this salutary lesson perhaps more eloquently than most in his philosophical treatise ‘The Myth of Sisyphus’ where, in a lyrical passage which is well-worth reading, he decries ‘If through science I can seize phenomena and enumerate them, I cannot for all that apprehend the world’.