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
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