How Doctors Think: Clinical Judgement and the Practice of Medicine

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.