How Doctors Think (Montgomery)

I recently read How Doctors Think by Kathryn Montgomery, a PhD in English Literature teaching at a medical school. Her book is ambitious; it attempts to describe how clinical judgment works, how medical education tries to teach it, and how it is not science. She attempts to characterize contradictions in medical practice, the problems of practical medicine, and the stark difference between a patient in an office and a statistic from a scientific study. It's interesting and thought provoking.

However, I was not persuaded by her thesis. Her writing style reminds me of a philosophy essay, defining terms, clarifying assumptions, and building up an argument against medicine as science. However, her scope is too narrow, her definitions too constrained. She addresses science in "the narrow, old-fashioned, positivist sense [...] certain, replicable, dependable." She acknowledges this as a straw man but proceeds to spend chapters trying to dissect it. I don't think it's a novel, useful, or applicable thesis. We already know not every patient is the same, not every diagnosis foolproof, not every medication replicable and dependable.

Her observations on clinical judgment are interesting but not revolutionary. She discusses our need for certainty in medicine, the strangeness of narrative in "science," and the role of medical student education. Her evidence base is unusual; she draws on literature, poetry, plays, maxims, and even a study she conducted on seating patterns at a conference. She draws on a personal story of her daughter and breast cancer which applies emotional leverage yet undermines her attempt at objective analysis. In the end, I think How Doctors Think makes interesting observations from the perspective of a non-clinician, yet it falls short in convincing me to change my perception of clinical judgment and medicine.

Image from Amazon, shown under fair use.