••Summer 2007/Vol. 11, No. 3

Book Reviews

How Doctors Think: Clinical Judgment and the Practice of Medicine | to pdf >>

by Kathryn Montgomery, PhD

Review by Vincent J Felitti, MD, FACP

Kathryn Montgomery, a Professor of Medical Humanities, has written a book about the way physicians think and how we came to think that way. Her book is an unusual combination of highly readable academic erudition with fascinating observations and insights. Its origins lie in a college course she once gave in the origins of scientific knowing, and the fact that a number of her advanced placement students sought letters of recommendation from her to medical school. Seeing her former students after their acceptance and entry to medical school, she quotes a pediatrician's description of first-year medical students as "looking like children who had been abused."1 But perhaps the nidus upon which this book crystallized was the diagnosis of breast cancer in her 28-year-old daughter. Professor Montgomery is on two medical school faculties where she has spent many years studying how physicians come to know what we know, do what we do, and think the way we think. "Misunderstanding the epistemology of medicine--how doctors know what they know--has damaging consequences for patients, for the profession of medicine, and for physicians themselves ... . The costs are great. It has lead to a harsh, often brutal, education, unnecessarily impersonal clinical practice, dissatisfied patients, and disheartened physicians."1:p6

This is a profound and important book that will be of interest to those many physicians who have gotten beyond the anxious burden of acquiring the core scientific knowledge of medical practice. She makes it clear that medicine is not a science, but a science-using practice with a collection of well-honed skills involving a special familiarity with death. "The physician's best clinical instrument--diagnostic or therapeutic--is the physician herself. How in the world is that capacity acquired?"1:p162 Michael Balint made a similar observation in the introduction to The Doctor, His Patient, and the Illness: "... by far the most frequently used drug in general practice was the doctor himself."2:p1 How this pharmacology of the human comes to be, even largely unconsciously, is the theme of the book.

The author describes how "What counts clinically is the ability to sort through incomplete and potentially imprecise information to determine what is going on with a particular patient and then, often without much in the way of certainty, to choose an effective course of action. This may come to seem like common sense, but, if so, it is common sense about very uncommon matters."1 Her productive re-exploration of her early statement that medicine is not a science, but a science-using practice, reminds me of a wonderful comment by Walsh McDermott: "Science is what validates 20th century medicine. I don't mean what it's based on; that's a totally different matter" (1974, comments in a post-graduate address.)a

She also explores why medical education is frequently brutalizing, leading to an impoverished clinical practice. Chapter 10, The Self in Medicine, makes good background reading for those administratively concerned about physician morale in the Permanente Groups. "Patients seen hurriedly, one by one, are likely to pose only diagnostic and technical rather than human or social problems. Physicians ... are distracted from the social and economic components of the maladies they treat."1:p177

"How best to live one's life is the central moral question for every human being, well or ill. Life-defining illness only sharpens the need for an answer."1:p196 Standing in witness to that problem is not the least of our responsibilities. In a time where evidence-based medicine has become the new mantra if not shibboleth of the engineering model of the physician, Kathryn Montgomery's analysis of the subtleties of the development and meaning of clinical judgment, and its relationship to the complex nature of medicine, is a welcome counterpoint.

a Walsh McDermott, MD. Professor of Medicine and Professor and Chairman of the Department of Public Health Cornell University. Extemporaneous comments in a post-graduate address at the Johns Hopkins Hospital.

References

1. Montgomery K. How Doctors Think. Oxford: Oxford University Press; 2006.

2. Balint M. The Doctor, His Patient, and the Illness. New York: International Universities Press; 1972.

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