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

Throughout her distinguished career as a medical humanist and medical educator, Kathryn Montgomery has drawn on her keen understanding of the ways in which narrative shapes human understanding and on her close acquaintance with how physicians are formed to make the case that medicine is significantly misunderstood when it is thought of as a science (Montgomery 1993). In How Doctors Think, she treats this idea not as a view to be argued against, but as an illusion that needs to be dispelled. Rather than providing a linear, cumulative argument—breaking down the sub-tasks that need to be achieved if the main thesis is to be supported, and proceeding to knock them down in proper sequence—her book circles its target, looking for the sources of the illusion's tenacity and mobilizing various solvents against the sticky places.

Indeed, Montgomery allows her target to drift about a bit. Her "official" point is that medicine is not science as the logical positivists conceived science to be—an enterprise that provides access to "an exact and unmediated representation of reality" (p. 10). But that, of course, doesn't take much showing these days: physics isn't science as the logical positivists conceived science to be. Montgomery's real concern is to account for why such a caricature continues to haunt both thought and practice, how it both helps and harms us, and why the harms outweigh the helps.

At times, however, the book's case against the medicine-as-science thesis seems mounted in a way that doesn't depend on such a dusty impression of what science is. The case against this version of the view seems to involve fairly technical points about different styles of inference that characterize clinical versus actual scientific reasoning, as if to say that even sophisticated accounts of science won't capture what is so distinctive and significant about how doctors think. Here readers may find a bit more to cavil about. For example, Montgomery claims that clinicians, unlike scientists, typically reason "abductively"—in other words, they start "from a particular phenomenon, and, using preliminary evidence, hypothesize its possible causes; those hypotheses are tested against details revealed by closer examination" (p. 47). Yet an abductive strategy—"inference to the best explanation"—is widely invoked as a staple of scientific reasoning. So perhaps her remarks here are directed against the official target, a positivist-flavored, yet still socially influential fantasy about what science is, rather than the real thing.

What seems most revelatory about the book's "therapeutic" agenda is the powerful and poignant story that unifies many of its chapters and all its major themes: the story of her struggles with her daughter's breast cancer. That recurring narrative thread is the heart of the book, and it starkly and sensitively poses a painful question that faces patients, those they love, and even doctors. If our lives include the kind of absurd irruption that confronts Montgomery, and if, like her, we are clear-sighted, we cannot pretend that medical understanding isn't severely limited—that its surest source of knowledge, abstract and general, misfits its domain of practice: individual, concrete, particular, anomalous people. Why, and to what extent, then, does it make sense for us to put ourselves into doctors' hands, to suffer interventions we don't fully understand and that will often harm us? What kind of understanding of medicine can sustain us when our children are very ill?

Debunking the medicine-as-science thesis doesn't solve this problem; if anything, it sharpens it. What is needed is an account of how doctors think, a version that accommodates what is really plain—that doctors aren't positivist scientists—but that they have powerful, authoritative, healing knowledge and the trustworthy values to direct it properly. Montgomery provides an account of clinical judgment that is inspired by Aristotle's notion of phronesis, or practical wisdom, and this strikes me as exactly the place to...