How Doctors Think: Clinical Judgment and the Practice of Medicine

By Kathryn Montgomery | Go to book overview

CHAPTER FOUR
“What Brings You Here Today?”:
The Idea of Cause in Medical Practice

Sergeant Lewis: “They don't make any sense.”
Morse: “Things never do until you find out.”

—COLIN DEXTER

MY DAUGHTER'S ILLNESS sent me on a quest to understand the idea of cause. To know the cause of disease is to have control. Medicine is driven by it, and patients and their families are part of that drive. And yet, as I discovered, the idea of cause in medical practice bears as odd a relation to science as clinical medicine itself. The physician's investigation of cause, even as it seems to confirm clinical medicine's status as a science, undercuts that claim at every turn.

The idea of cause fits right into the misdescription of medicine because it is central to the profession's conventional, positivist ideal of science. Yet in the physician's office or the emergency room, cause is the object of a retrospective, narrative investigation that more nearly resembles investigation in history or economics than experiments in microbiology or chemistry. The face-to-face encounter with a patient gives what the physician knows about biological cause a practical, taken-for-granted, confirmatory role. What science has yet to discover seldom comes to mind—and then only in truly puzzling cases. Physicians instead are in pursuit of a diagnosis, the cause of the patient's illness, and this causal pursuit is framed as science rather than as simply a rational inquiry. Yet a look at the clinical uses of cause reveals some of the important ways clinical medicine differs from a Newtonian science and highlights instead medicine's practical rationality, the clinical judgment essential to the work of diagnosis and treatment. At the same time, the importance of clinical cause

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