How Doctors Think: Clinical Judgment and the Practice of Medicine (review)

The practice of medicine: neither science nor art

Kathryn Montgomery's new book, How Doctors Think, addresses the thorny question of clinical judgement: of how doctors bring their knowledge and reasoning to bear on the problems of an individual patient, and how, even in this most technological of times, it remains essential to good medical practice. She explores what it is, how it is formed and taught, and the consequences of ignoring it in favour of a simplistic belief in medicine as merely another positivist science. She succeeds in bringing what Eric Cassell has called `steel' to the task, and she succeeds brilliantly. If the outsider sees more of the game, then Kathryn Montgomery, who describes herself as a licensed trespasser on clinical territory, has a ringside seat. A literary scholar who has worked in medical schools all of her professional life, for the last twenty years as professor of medicine and director of the medical humanities program at North-western University, she has been observing doctors and doctoring for all that time. Throughout her book she uses her literary skill to show us what we do and how we do it and how that affects patients, families and ourselves. And always there are the stories; the narratives that bring her themes into sharp focus. Thus the opening section `Medicine as a Practice' draws heavily upon her own account, as the mother of a 28-year-old daughter diagnosed as having an invasive ductal carcinoma of the breast, to show how the limits of the knowledge we possess makes medicine, in so far as it is applied individually to single cases, more of a social than an exact science. Narrative too plays a crucial role in the two central sections of her book, `Clinical Judgement and the Idea of Cause' and `The Formation of Clinical Judgement'. Using doctors' aphorisms, maxims and rules of thumb, as well as patients' often inchoate `histories', she shows us how physicians arrive at a clinical judgement about the person in front of them; how they negotiate ambiguous alternatives and tolerate uncertain, or at least incomplete, answers and how reluctant they are to burden the vulnerable seeking certainty with the imprecision of their own knowledge. The book's closing section, `Clinical Judgement and the Nature of Medicine', is perhaps the most challenging. Here Montgomery shows, with example after example, just why we should see medicine, not so much as a science but rather as situational reasoning serving a practical end; an endeavour based upon, but distinct from, medical science; the practical ability to select those pieces of knowledge that will determine what is best for this individual patient. Here, as she did in Doctors' Stories, she shows us just how discerning a skilled listener can be when faced with even the most seemingly trivial. This is a book that will be read with pleasure by anyone interested in how medicine is done and it is a book that should be required reading for all students starting their clinical training.

How Doctors Think defines the nature and importance of clinical judgement. Although physicians make use of science, this book argues that medicine is not itself a science but rather an interpretive practice that relies on clinical reasoning. A physician looks at the patient’s history along with the presenting physical signs and symptoms and juxtaposes these with clinical experience and empirical studies to construct a tentative account of the illness. How Doctors Think is divided into four parts. Part One introduces the concept of medicine as a practice rather than a science; Part Two discusses the idea of causation; Part Three delves into the process of forming clinical judgement; and Part Four considers clinical judgement within the uncertain nature of medicine itself. How Doctors Think contends that there can be adverse side effects to assuming that medicine is strictly science, and suggests reducing these by recognizing the vital role of clinical judgement.

K athryn Montgomery is a professor of medical humanities at Northwestern University in the United States and a literary scholar by training. Her thesis is that doctors (and patients) misrep-resent...

Science: a limited source of knowledge and authority in the care of patients*. A Review and Analysis of: ‘How Doctors Think. Clinical Judgement and the Practice of Medicine.’Montgomery, K.

Montgomery, Kathryn, How Doctors Think: Clinical Judgment and the Practice of Medicine

How Doctors Think: Clinical Judgement and the Practice of Medicine

Kathryn Montgomery Oxford University Press USA, 2012 , PB, 256 pp, £20.49, 978-0199942053 Kathryn Montgomery’s classic text is even more relevant to medical education and practice today than when it was published a decade ago (originally in 2005). The author acknowledges the benefits of biomedical science but argues that clinical medicine is not a science but an interpretative practice. She points out a central paradox in medicine, the disparagement of anecdote, regarded as the lowest level of evidence. …

How Doctors Think: Clinical Judgment and the Practice of Medicine

Delivering resilience will require innovative systems-thinking skills of practical wisdom that go beyond technique. Aristotle's notion of phronesis as practical wisdom, which was largely lost until contemporary thinking about virtue ethics, provides a basis for a modern interpretation. Resilience, risk, vulnerability, robustness and sustainability need to be set not just in the dominant paradigm of scientific/technical rationality but also within a reflective practice that nurtures practical wisdom and questions ‘why’ before ‘how’. Practical rigour, as part of practical wisdom, is the meeting of a need by setting clear objectives involving many values (some in ‘wicked’ conflict) and reaching those objectives in a demonstrably justifiable way. Seven elements in practical rigour are described. Two keys to delivering resilience are: (a) to allow professionals to publicly admit that we do not know when we genuinely do not know; (b) to integrate people, purpose and (old) process through collective practical wisdom emerging from collaboration and learning together.

Reader in Applied Philosophy, Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK and Visiting Professor of Philosophy as Applied to Medicine, University of Buckingham, Uk Assistant Professor, Department of Philosophy and Religious Studies, Old Dominion University, Norfolk, VA, USA Associate Professor, Department of General Practice, University of Auckland, Auckland, New Zealand Director, University of Toronto Joint Centre for Bioethics, Toronto, ON, Canada Assistant Professor, Department of Philosophy, University of Guelph, Guelph, ON, Canada Assistant Professor, Department of Philosophy, Dalhousie University, Halifax, NS, Canada Professor of Values in Health Care, Associate Director, Social Dimensions of Health Institute, University of Dundee, Dundee, UK

Listening to the story of medicine

John Tribe's paper 'Education for Ethical Tourism Action' (10 (4), 2002) proposes an action-oriented ethical tourism curriculum based on Aristotle's notion of phronesis, aimed at developing a disposition towards 'good' action rather than 'correct' action. This paper investigates the implications of Tribe's paper for the pedagogy and practice of sustainable tourism. Drawing upon Aristotle, it is argued that principles are an important guide to developing and exercising phronesis (practical wisdom) for living a good life, and for the practice of sustainable tourism. The paper also examines issues related to theoretical or scientific knowledge (episteme) and skill development (techne), and argues for a praxis-oriented curriculum that incorporates: (1) knowledge of sustainable-tourism principles, and (2) practice in which learned principles and phronesis (practical wisdom) constitutively guide tourism action and good conduct. The study also suggests that scholars and practitioners need to be more proactive and cognisant of the telos (purpose) and good of various tourism activities and curricula, for the individual and for the destination. Especially lacking in the study of sustainable tourism is discussion of the development of virtues and character for a good life in and through tourism. Virtue ethics offers potential for supplementing existing theories of rightness and obligation in sustainable tourism, and for conceptualising the meaning of 'good tourism'.

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a...

Hans‐Georg Gadamer (1900–2002) is the founder of modern‐day philosophical hermeneutics. His relevance for ethics lies mainly in the fact that he relied on Aristotle's notion of phronesis (practical wisdom, prudence) to describe the hermeneutic experience of understanding and in his strong defense of Aristotle's conception of ethics, with its insistence on custom shaped by education and tradition, which helped usher in a rehabilitation of a practical philosophy that does not follow the Kantian model of a universalistic, normative ethics.