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September 25, 2007

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Well, I do look forward to these lexicon entries and this one was certainly worth the wait. I like the careful and articulate distinction between medical research and therapy. I wonder how much doctors who see their profession as resting, in the end or at bottom, on the (anticipated, eventual...) success of scientific research see themselves as involved in a scientific enterprise that aims for a kind of objectivity inappropriate for the therapeutic situation (I would not therefore characterize the therapeutic situation as wholly subjective). For example, as Kathryn Montgomery reminds us, "Physicians draw on their diagnostic skills and clinical experience as well as scientific information and clinical research when they exercise clinical judgment." This often leads, she argues, to the misdescription of medicine as a science (something 'medical humanities folks' are constitutionally disposed to recognize and appreciate) inasmuch as clinical practice in general and clinical judgment in particular is reliant on something as elusive and circumstantial as Aristotelian phronesis or practical reasoning, however much it draws from the fund of science and technical knowledge: "Physical symptoms are read narratively, contextually, and interpreted in cultural systems. A physician's diagnosis is a plot summary of a pathophysiological sequence of events. The lump is there. It is a sign, caught *in media res*, a clue to a natural history that is unfolding. Science describes and explains it and determines what can be done about it. But the importance of that lump, the acts its discovery entails, and what those acts will mean are social and cultural matters." And the consequent danger: "...[M]edicine's status in society depends in large part on the scientific character of much of its information. To claim to be a scientist in our culture is to stake out authority and power. But physicians suffer the ill effects of this hubris: as patients and as citizens, we expect them to be far more certain than either their practice or the biology on which it is based can warrant, and, for many reasons, they are likely to take these expectations for their own. Malpractice suits that arise more from anger over misplaced expectations and perceived neglect than from genuine mistakes are the result." No matter how successful evidence-based medicine proves to be, it "will not turn medicine into a science." The quotes are from Montgomery's How Docotrs Think: Clinical Judgment and the Practice of Medicine, 2006).

Hey Patrick,

Thanks for the insight. Kathryn Montgomery's book is excellent, and I am somewhat surprised it has seemed to be swallowed up by Groopman's similarly titled book, esp. b/c I think the former is a much thicker analysis.

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