How Doctors Think: Clinical Judgment and the Practice of Medicine

by Kathryn Montgomery

How Doctors Think defines the nature and importance of clinical judgment. 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 judgment; and part four considers clinical judgment within the uncertain nature of medicine itself. In How Doctors Think , Montgomery contends that assuming medicine is strictly a science can have adverse side effects, and suggests reducing these by recognizing the vital role of clinical judgment.

Genres: Medicine, Philosophy, Nonfiction, Medical

246 pages, Hardcover

First published October 27, 2005

Reviews

[Gijs Limonard · Rating 5 out of 5]

Finally, a book any clinician can relate to. Medicine is often considered both a science (episteme) and an art or craft (techne). The author makes the claim it is neither. Phronesis is the practice of making pragmatic decisions and taking action in uncertain or incompletely understood situations, in order to reach a desired outcome. Clinical decision making and clinical judgment fit this bill perfectly. Clinicians: read and have a massive aha-erlebnis. Patients: read and you'll better understand your doctor. Highly recommended.

[Samuel Brown · Rating 3 out of 5]

Her fundamental argument is that the "art vs. science" of medicine construct is deeply confused and misleading. Medicine's relationship to science is complex, and most clinical medicine is probably best understood as _phronesis_, the practical reasoning and problem solving described by Aristotle. I find that argument quite persuasive and well elaborated.

She does a fair bit of work with postmodern philosophers, and I find myself more interested in cognitive psychological models of clinical phronesis than postmodernism. She works in parallel to advocate a shared acknowledgment of the ineluctable uncertainty that characterizes medicine, and this is an important take on an important topic, although I found myself wanting it to be a little better developed.

[Madhusree · Rating 4 out of 5]

Fascinating read- approaches the medical world & its balancing act of constant trade offs, just as all of us will, one day. The writing is readable, occasionally even lyrical and I found reading a practice in self reflection. Would recommend it to anyone with an interest in diagnosis in medicine.

[Tsung · Rating 4 out of 5]

Insightful book. Although it doesn't fully get into the mind of the physician. Interesting observations and concepts. Tackles from a epistemological and philosophical perspective. Argues that the axioms "Medicine is a science" and "Medicine is an art" are bandied about but not properly defined. Proposes that medicine is a practice and clinical judgement lies at the crossroads of "science" and "art". The themes are repeated ad nauseum throughout the book. I think partly because the chapters were previously published separately. Chapter nine seemed incongruous with the book and should have been omitted. Overall a good read, especially for those involved in teaching medicine.

[Razan Aldawod · Rating 1 out of 5]

I'd expected better of this book for some points,
some of the chapters eg the taking history part and clinical judgment were obviously logical regardless of their descriptions. Second, is looking at the number of the pages compared to the useful content is overrated.

[David R Munoz · Rating 5 out of 5]

An excellent treatise on the art of knowing and mastering the anxiety of not knowing

An excellent review of how we approach the cognitive aspects of medical practice. Medicine shares a method of applied expertice with many other disciplines.

[Rebecca · Rating 5 out of 5]

An interesting insight into doctor's. Medicine is not very straighforward at all and doctor's need to think creatively and keep an open mind.

[Chris Friend · Rating 4 out of 5]

Interesting, informative, and very well-told. What all nonfiction should be.

It gets a bit repetitive at times, but not fatally so.

[Jeremy Steinberg · Rating 2 out of 5]

The book has the occasional insightful comments but it is largely filled with constructivist nonesense.

[Mike · Rating 4 out of 5]

I began to read this book for a course that in english would be called "Teaching clinical method in medicine", although my professor concluded (and I agree) a more proper name would be "Clinical reasoning".
The book goes beyond clinical judgment and the practice of medicine; in a way that to me was if not exhaustive at least enumerative, the author gathers several paramount examples about the relation of literature, philosophy, ethics, history, economics and several other fields with medicine and medical education.
The core of the book is the author's opinion that medicine is not a science and the development of this idea; its arguments and counterarguments, pros and cons. As a physician myself, I have to admit that at first sight that proposition seemed if not an attack at least a rude opinion. Well, my feeling about it changed and I will tell you how is that I realized the change.
Due to a number of mandatory and simultaneous lectures I moved about the book for a whole year! Coming and going to already read chapters because sometimes I had forgotten what was it about. The tone of my annotations and underlining on the book was modified gradually. The introduction was full of sarcastic (electronic) sticky notes expressing my annoyance to the author, this enhanced by my consideration of her as a layperson. Well, time goes by and things evolve. I decided to re-read some parts of the book and bang, there it was: she was right.
At the moment I obtained something very valuable, a definition of medicine which I will use maybe for the rest of my life: an acquired, culturally engendered, communally reinforced, flexible, situationally sensitive, interpretive, narrative-aided, science based, abductive, rational practice (dialogic and aphoristic in character). In short: medicine is a practice. How? Why? Well, read the book.

[Minh Đức · Rating 5 out of 5]

This book is for pre-med students who want to extend their careers as physicians or anyone who curious about the practice of medicine and the science itself. During my clinical rotation, these questions just grew bigger and bigger since all the answers I received a un-organized or un-clear sometimes. Kathryn, despite not having an MD degree, does understanding in deep about how doctors think.
"When you hear hoofbeats, don't think zebras"
"Experiences is the ground of medicine's rules of practice, then research flows from it"

[Trinity.j_205 · Rating 2 out of 5]

I was expecting that this book would help me become more familiar with medical terminology, and decisions made in emergency scenarios.
Except I found that it was repeating the same vague points, about whether Medicine is an art or a science.
Occasionally there were insightful comments, but the rest was just circumlocutory.

Overall I feel as though I didn’t take as much out of this book as I was hoping to.

[Ashley · Rating 5 out of 5]

Cannot recommend this book more. So helpful to me as a budding clinical ethicist!

[Zhifei Ge · Rating 3 out of 5]

The title of the book is misleading. It had better call itself How Doctors Should Think, rather than How Doctors Think. There is substantial difference between the two. The latter is about description of facts, i.e. how clinical decisions are made in hospitals. The former is philosophical, and upon that how medical school curricula should be changed.
The writings of the book is argumentative, full of arguments, while I wish the book had been more narrative. I can understand the author is very thoughtful. But, more stories, please!
With all its defects, the book has its own merits. Some highlights of the book:
Take-home suggestions by the author, "Experience is the best teach." and "Learn from others' mistakes". "Pattern your practice on that of your clinical elders." and "Question everything your are told and much of what you see." The authors suggestions of always keeping paradoxes in mid is very insightful. Above all, clinical decisions are full of paradoxes.
"Those who possess this rational capacity or virtue in great measure are often regarded as wise. Yet, as the philosopher Charles Taylor has pointed out, rationality as a whole has come into ill repute precisely because contemporary Westerners have no standard except science for what is rational." The authors emphasis on the significance of practical reasoning in clinical decisions is the core of the book. This is really inspiring. As most people have been mentally trapped in science, me included.

[Jonathan Berry · Rating 5 out of 5]

A really excellent and thought-provoking piece on the nature of medical knowing.