Thursday, 24 January 2008

How Doctors Think

Yesterday I somehow found the time to read Kathryn Montgomery’s recent book How Doctors Think (OUP 2006). The central idea is that medicine misdescribes itself in positivist terms and fails to appreciate that it is founded on - and indeed this is what medical education is directed at producing - clinical judgement, which it explicitly links to Aristotelian phronesis.

The widespread misdescription of medicine as a science and the failure to appreciate its chief virtue, clinical judgement or phronesis, amounts to a visual field defect in the understanding of medicine. In medical-philosophical terms, the misunderstanding of clinical reasoning is an epistemological scotoma, a blindness of which the knower is unaware. [Montgomery 2006: 5]

It is an interesting and well written book and I’ll certainly invite Montgomery to contribute to an edited book on tacit knowledge and clinical judgement I’m planning, if she’s interested. But it is also significantly different in (at least) three respects from work in the philosophy of psychiatry.

1. Montgomery has a PhD in English literature and moved into medical humanities (of which she is a professor in a medical school) through teaching medical students who had to take English courses. As a result of this background, I assume, it is a very different kind of book to a philosophical account of clinical judgement. Philosophers are mentioned (largely in footnotes) but the account of the nature of clinical judgement is developed more through an oblique accumulation of anecdote than an explicit argument. Since one of the claims of the book is that medicine has been blind to the role of judgement in favour of a positivist model of science, perhaps that is deliberate. Perhaps a more explicit argument would have smacked of the kind of rationality she distrusts.

2. There is something a little odd about the fact that science is only discussed according to a 1930s positivistic model. Part of the main claim is that medicine’s self image is, inaccurately, that of positivistic science. Since that is how clinicians conceive themselves, that is the model of science present in this book. But it surely raises the question, would clinicians be wrong to think of medicine, not along this widely rejected model, but the one (or ones) developed since the 1960s? Once one steps outside the conception of the world as apparently held by American clinicians, the substantial question to ask is surely: what really is the connection between clinical judgement and science, on the most accurate account of science we have?

3. But the third aspect is most striking and marks the difference between this book on medicine as a whole and the literature of philosophy of psychiatry. Despite the accusation of suffering from an intellectual scotoma, the book is consistently laudatory of modern medicine in the US. There is a suggestion that economics, which impact via managed care or insurance, may have a harmful effect. But the medicine and the clinicians are mainly all just fine. (They are in some sense more adult than the rest of us - see ch10.) This tone is reinforced by a personal anecdote at the end of the book. Despite her own extensive knowledge of the evidence concerning her daughter’s breast cancer she is thankful to be able to place her trust in the self-consciously authoritative claims of a doctor on a car journey, unacquainted with the particular case, even knowing his own narrow range of experience.
Perhaps because of the anti-psychiatry movement, I know of no philosophy of psychiatry books with such a deferential tone. There, there is always the possibility, even if only in the bowels of Christ, that psychiatry may be wrong. Philosophy of psychiatry need not be hostile to psychiatry - as anti-psychiatry obviously is - but it is refreshingly critical.

The one thing that did seem simply lacking in the book, especially given its author's background, was an account of narrative. One of the contrasts deployed is between the form of intelligibility of (only positivistic?) science and clinical judgement with ‘narrative’ used to help characterise the latter. But as is often the case, it would be nice to know a little more about what narrative intelligibility is supposed to be. Clearly in this book it is contrasted with subsumption under universal laws of nature (not that it puts it quite that way). But it did not seem to have to include meaningful elements of verstehen-type understanding (my own best bet for an interpretation of the term). So there’s a research project: what do defenders of narrative approaches mean by narrative? Is there something they all have in common? What constraints does the idea of narrative impose (if no constraints, there's no substance to the term; but if the narratives have to look like Jane Austen but not Alain Robbe-Grillet, is that true)?