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. (shrink)

Phenomenology is a useful methodology for describing and ordering experience. As such, phenomenology can be specifically applied to the first person experience of illness in order to illuminate this experience and enable health care providers to enhance their understanding of it. However, this approach has been underutilized in the philosophy of medicine as well as in medical training and practice. This paper demonstrates the usefulness of phenomenology to clinical medicine. In order to describe the experience of illness, we need a (...) phenomenological approach that gives the body a central role and acknowledges the primacy of perception. I present such a phenomenological method and show how it could usefully illuminate the experience of illness through a set of concepts taken from Merleau-Ponty. His distinction between the biological body and the body as lived, analysis of the habitual body, and the notions of motor intentionality and intentional arc are used to capture the experience of illness. I then discuss the applications this approach could have in medicine. These include narrowing the gap between objective assessments of well-being in illness and subjective experiences which are varied and diverse; developing a more attuned dialogue between physicians and patients based on a thick understanding of illness; developing research methods that are informed by phenomenology and thus go beyond existing qualitative methods; and providing medical staff with a concrete understanding of the impact of illness on the life-world of patients. (shrink)

The claims of randomized controlled trials to be the gold standard rest on the fact that the ideal RCT is a deductive method: if the assumptions of the test are met, a positive result implies the appropriate causal conclusion. This is a feature that RCTs share with a variety of other methods, which thus have equal claim to being a gold standard. This article describes some of these other deductive methods and also some useful non-deductive methods, including the hypothetico-deductive method. (...) It argues that with all deductive methods, the benefit that the conclusions follow deductively in the ideal case comes with a great cost: narrowness of scope. This is an instance of the familiar trade-off between internal and external validity. RCTs have high internal validity but the formal methodology puts severe constraints on the assumptions a target population must meet to justify exporting a conclusion from the test population to the target. The article reviews one such set of assumptions to show the kind of knowledge required. The overall conclusion is that to draw causal inferences about a target population, which method is best depends case-by-case on what background knowledge we have or can come to obtain. There is no gold standard. (shrink)

This paper explores the relationship between concepts of probability and hermeneutics. It seeks to examine the relationship between subjective (Bayesian) views of probability and hermeneutic descriptions of understanding. It is argued that Gadamer'saccount of the prejudicial nature of understanding, derived from Heidegger'sanalysis of foreunderstanding, offers a provocative model of clinical reasoning. The implications of this model for evidence-based medicine are discussed in conclusion.

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five (...) distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. (shrink)

Cartesian dualism has been viewed by medical theorists to be oneof the chief causes of a reductionist/mechanistic treatment ofthe patient. Although I aver that Cartesian dualism is one culprit for the misapprehension of the genuine treatment of patients in termsof both mind and body, I argue that interactive dualism whichstresses the interaction of mind and body is essential to treatpatients with dignity and compassion. Thus, adequate medical carethat is humanistic in nature is difficult (if not impossible)to achieve without physicians adhering (...) to a dualistic frameworkin which the body and person is treated during illness. (shrink)

Biology as a scientific discipline has relied heavily upon advances in chemistry and physics. An inherent danger in this relationship is the reduction of living phenomena to physico-chemical terms. Whitehead's Philosophy of Organism is utilized to examine current methodologies within biology and to evaluate their appropriateness for future research. Hemostatic regulation is employed to illustrate the applications of organistic concepts to biological research. It is concluded that understanding of living entities and their properties as well as possibly life itself will (...) require synthesis of the many analytical elements as informational structures. (shrink)

Clinical medicine is the application of scientific principles, rules of thumb, and a store of practical wisdom embodied in narratives of individual cases to the care of a person who is ill. Physicians are taught to observe and report the individual case both as a means of fitting nomothetic generalizations to the given circumstances and as a way of refining those generalizations. This narrative construction of illness is a principal way of knowing in medicine. In this view, disease is not (...) so much an entity as an identifiable chronological organization of the events of illness, and medicine, rather than a science, a rational science-using activity in the service of the ill. Keywords: medical epistemology, casuistry, clinical judgment, narrative CiteULike Connotea Del.icio.us What's this? (shrink)

How physicians approach patients and the problems they present is much influenced by the conceptual models around which their knowledge is organized. In this paper the implications of the biopsychosocial model for the study and care of a patient with an acute myocardial infarction are presented and contrasted with approaches used by adherents of the more traditional biomedical model. CiteULike Connotea Del.icio.us What's this?

Engages with the impact of modern technology on experimental physicists. This study reveals how the increasing scale and complexity of apparatus has distanced physicists from the very science which drew them into experimenting, and has fragmented microphysics into different technical traditions.

In this book the author explores the shifting philosophical boundaries of modern medical knowledge and practice occasioned by the crisis of quality-of-care, especially in terms of the various humanistic adjustments to the biomedical model.

The continuing discovery of important Hegel manuscripts and advances in the criticism of Hegel's works have set the stage for a major reevaluation of one of the greatest philosophers of all time. This volume constitutes the comprehensive reinterpretation of Hegel that has long been needed.The first chapters are devoted to the influences of other German philosophers on Hegel, his early publication as they are relevant to his later writings, and his Phenomenology--in itself and as a key to understanding his terminology (...) and dialectic. Examined next are the further elaboration of his thought in Logic; his famous system, as presented in various editions of the Encyclopedia; and his little-known views on history. A final chapter details in letters and contemporary reports Hegel's intellectual development. (shrink)

The proposed practice of "evidence-based medicine," which calls for careful clinical judgment in evaluating the "best available evidence," should be differentiated from the special collection of data regarded as suitable evidence. Although the proposed practice does not seem new, the new collection of "best available" information has major constraints for the care of individual patients. Derived almost exclusively from randomized trials and meta-analyses, the data do not include many types of treatments or patients seen in clinical practice; and the results (...) show comparative efficacy of treatment for an "average" randomized patient, not for pertinent subgroups formed by such cogent clinical features as severity of symptoms, illness, co-morbidity, and other clinical nuances. The intention-to-treat analyses do not reflect important post-randomization events leading to altered treatment; and the results seldom provide suitable background data when therapy is given prophylactically rather than remedially, or when therapeutic advantages are equivocal. Randomized trial information is also seldom available for issues in etiology, diagnosis, and prognosis, and for clinical decisions that depend on pathophysiologic changes, psychosocial factors and support, personal preferences of patients, and strategies for giving comfort and reassurance. The laudable goal of making clinical decisions based on evidence can be impaired by the restricted quality and scope of what is collected as "best available evidence." The authoritative aura given to the collection, however, may lead to major abuses that produce inappropriate guidelines or doctrinaire dogmas for clinical practice. (shrink)

I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts. The literary critic reading a novel, the judge asked to apply a law, must arrive at a coherent reading of their respective texts. Similarly, the physician interprets the text of the ill person: clinical signs and symptoms are read to ferret out their meaning, the underlying disease. However, I suggest that the hermeneutics (...) of medicine is rendered uniquely complex by its wide variety of textual forms. I discuss four in turn: the experiential text of illness as lived out by the patient; the narrative text constituted during history-taking; the physical text of the patient's body as objectively examined; the instrumental text constructed by diagnostic technologies. I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutic self-understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject — the living, experiencing patient. (shrink)