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Perspectives Book The practice of medicine: neither science nor art “I have pneumonia”, the 41-year-old, I was uncomfortable with the about diabetes to sink a galleon, but afebrile, Pakistani pharmacy assistant whole process—an unharmonious there is no invariant law that will told me cheerfully. “I’m coughing, my hodgepodge of science, experience, predict exactly what will transpire in fever was 102 last night, and it hurts gut feeling, and a host of social my patient with his unique constella- when I take a deep breath”, he said, circumstances unrelated to medicine. tion of glucose control, pulmonary pointing to the right side of his chest, It is with this discomfort that pathology, drug absorption, cultural exactly where I heard the crackles. With KathrynMontgomery begins her book, expectations, financial constraints, his limited medical knowledge, my How Doctors Think: Clinical Judgment and personality quirks. patient was able to come to the diagno- “Why is it that it is so difficult to Yet we doctors insist on claiming a sis with the same accuracy as a medical scientific mantle for medicine. Of course student, an intern, an attending, or define clinical judgment, and we admit to the uncertainties that exist, How Doctors Think: Clinical even a simple computerised algorithm. why do we doctors squirm when but “further research” and cures are Judgment and the Practice of Cough+fever+pleuritic chest pain + we are forced to admit just how always on the horizon. Evidence-based Medicine crackles = pneumonia. A chest radi- reliant we are on it?” medicine will continue to scour the Kathryn Montgomery. Oxford University Press, 2005. ograph would have been handy—and murky corners of medicine like an NIH- US$39·50. Pp 256. I ordered one—but the result would and the Practice of Medicine. Why is it anointed Hoover vacuum. But despite ISBN 0-195-18712-1. taketime. I had to make decisions now: that it is so difficult to define clinical what doctors and patients wish to inpatient versus outpatient treatment, judgment, and why do we doctors believe, medical science will always be broad-spectrum versus narrow- squirm when we are forced to admit an asymptote. Medical “facts” will never spectrum antibiotics, horse (pneumo- just how reliant we are on it? fill the infinite space created by the nia) versus zebra (pulmonary embolus). The heart of the discomfort, variety of human health and pathology. While there might have been a large, Montgomery deduces, can be traced Midway through writing this book, prospective, double-blind, placebo- back to a fundamental “misdescription the author’s 28-year-old daughter controlled study of healthy, uninsured, of medicine”. For doctors and the discovered she had breast cancer. mildly diabetic, previously febrile but public, medicine is fundamentally a Montgomery was afforded the unfor- currently afebrile, Pakistani men in the science: doctors have years of scientific tunate opportunity to experience the diagnosis and treatment of presump- training in medical school. Medical text- vagaries of medical thinking while tive community-acquired pneumonia, I books are factual tomes crammed with simultaneously shining her academic wasn’t aware of it, and for sure didn’t fine-print citations. Doctors read med- lens on it. Her conclusion is that rather have the time to go hunting on Medline ical journals brimming with complex than being a true science (or an art— with eight other patients waiting to see clinical trials. Doctors’ opinions are a cut Montgomery isn’t sure what that term me. So I found myself in the unenviable above those of a shaman or Aunt Ethel connotes), medicine is really a practice. but common position of being forced because they are backed up by science. Doctors tend to cringe at the to act in the absence of having every Doctors wear white coats, just like thought of medicine being defined by scientific fact in place. That is, I was scientists, and even call them lab coats. clinical judgment rather than by hard forced to make a clinical judgment. But all these things are to some science. Clinical judgment is often seen The minutes ticked by as my mind extent illusory. Montgomery states in as a smokescreen for not having read reeled back to the other patients I’d print what we’ve had a sneaking suspi- this week’s NEJM or Lancet. Perhaps treated, the journal clubs I’d taken part cion about all along: medicine really this is an issue of pride, but most in, the textbooks I’d read, the CMEs isn’t a science, in the true Newtonian doctors, as Montgomery found, do not I’d attended, the infectious disease sense. In the world of physical sciences react well to having their thought consultants I’d spoken with. I squinted there are absolute laws—of motion, of processes compared with those found at my patient, assessing my Gestalt thermodynamics, of gravity; absolute in the social sciences. She suggests that of his appearance, his vital signs, his laws from which deviance does not— “science is a tool, rather than the home situation, his reliability, his lan- cannot—exist. Medicine is almost the soul of medicine” and that medicine guage skills, the speed of the radiology living antithesis of this. The biological “is neither a science nor an art. It is a department, the dependability of our variability of disease, human beings, distinctive, practical endeavor whose answering service for late-night calls, and the human condition make such particular way of knowing . . . qualifies my level of risk aversion—and then I assured rationality almost laughable. it to be that impossible thing, a science made a decision. Yes, there has been enough written of individuals”. www.thelancet.com Vol 367 March 11, 2006 807 Perspectives In the “problem of particularizing”, elderly patients usually have multiple with academic jargon at times, but Montgomery shows the limitations of illnesses. These aphorisms actually there are enough moments of personal treating medicine like science. Physical are not contradictory, they are simply recognition to make it a worthwhile rules are absolute, but medical ones realistic observations of the complex read for experienced physicians. are only rough guidelines. The essence spectrum of disease. (Imagine Patients want certainty; doctors of clinical judgment is knowing chemists saying that all elements strive to offer certainty. Science offers when the rules don’t apply, or, how respect Avogadro’s law, apart from an illusion of certainty that belies its to particularise an observation that all the ones that don’t.) ability. Clinical judgment is perhaps a has been made on a population to Montgomery is not a physician, but a more realistic assessment of how theobstreperously unique individual. social scientist who studies physicians. doctors think and what we can offer Moreover, individual patients have There are those oncologists who might our patients. Montgomery, having the annoying habit of neglecting quibble with her statement that there exhaustively researched her daughter’s to read the textbooks, presenting with is no “cure” for any form of breast illness, can cite chapter and verse about unique symptoms and paradoxical cancer. And some infectious disease genetic mutations and 5-year survival data. Luckily, medicine—as a practice, specialists who might cringe at her rates. But it is the clinical judgment of not a science—can absorb that. description of mycoplasma as a prion. an experienced surgeon, who tells her Montgomery points out how But she is an astute observer of medical that in all his years of practice that he’s medicine easily integrates seemingly thought and behaviour, from how hier- only lost one patient with stage I breast contradictory clinical pearls. The archy affects seating arrangement in cancer, that comforts her the most. primacy of clinical judgment allows medical conferences to how expecta- physicians to know Occam’s razor of tion and desire fundamentally shape Danielle Ofri parsimony, but also keep in mind that thought. The book can be a bit dense danielle.ofri@med.nyu.edu In brief Book A scientific sage comprehensive work, Andrew Brown all that in-your-face brightness. The There is something titanic—in both brings out Bernal’s astonishingly Flavin retrospective is unquestionably senses of faded classical grandeur and polymathic range of interests and one of a kind, and does more for a doomed hubristic excess—about the his unconventional personal life. colour collection of tubes than most generation of British academics that Brown provides an object lesson people have ever thought of. But flourished between 1918 and 1945. in contextualising what might at Afterimage, the response of three UK Bertrand Russell, A J Ayer, Julian first glance be rather dry laboratory scientists to Flavin’s work, shows that J. D. Bernal: The Sage of Science Huxley, Haldane (J S and J B S): the very science. Apart from taking its place as interesting lights and colours appear Andrew Brown. Oxford names evoke a time of communist the best existing account of Bernal’s not only in electric light tubes, but University Press, 2005. Pp 562. cells in common-rooms, of pipe smoke life and work, Brown’s book provides are also found in minerals, teeth, £25·00. ISBN 0-19-851544-8. and free love, of men equally at home an inspiring introduction to the scorpions, currency, sunscreen, soap, in the drawing-rooms (and beds) of academic culture of the 1920s and zebrafish, tonic water, and much else. the Bloomsbury group and on the bar- 1930s, a period which to those living A cabinet of such curiosities is ricades with the Red Brigades. But any through it seemed to overflow with thestar of this modest but fascinating feeling of admiration for these men is hope, challenge, and passion. show. It is accompanied by a tinged with a sense of their naivety, Wimshurst Machine, a static genera- as if the post-Hiroshima world has Richard Barnett tor, and White Shadows & White Light, proved to be at once more cynical and ucgarba@ucl.ac.uk a demonstration of colour perception more complex than any of these sup- and afterimages. Clever, imaginative, posedly great thinkers could conceive. Exhibition Switched on this bit of counter-programming also Dan Flavin: A Retrospective At the centre of this group stood Exhibit-goers who tire of the innova- goes a long way towards explaining Afterimage J D “Sage” Bernal, crystallographer and tive, minimalist, and, frankly, it must be how Flavin’s work is perceived and Two exhibitions at the Hayward roué, household god and eminence said, nauseating, effect of the fluores- interpreted. Gallery, London, UK, showing grise to several generations of cent-light works of Dan Flavin should until April 2, 2006. www.mlythgoe.com/ politically inclined scientists and hie themselves to the Hayward Gallery Faith McLellan 19Afterimage.htm scientifically minded politicians. In this for a welcome, and quieter, antidote to f.mclellan@elsevier.com 808 www.thelancet.com Vol 367 March 11, 2006
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