How Doctors Think: Clinical Judgment and the Practice of Medicine

By Kathryn Montgomery | Go to book overview

CHAPTER SIX
Clinical Judgment and the
Problem of Particularizing

Talk to me
so we can see
what's goin' on …

—MARVIN GAYE

IF MEDICINE WERE practiced as if it were a science, even a probabilistic science, my daughter's breast cancer might never have been diagnosed in time. At 28, she was quite literally off the charts, far too young, an unlikely patient who might have eluded the attention of anyone reasoning “scientifically” from general principles to her improbable case. Luckily, medicine is a practice that ignores the requirements of science in favor of patient care.

Deduction is the label Sherlock Holmes uses for his rational skill, and physicians, who find medicine's investigative procedures mirrored in his practice, have adopted the term to describe their thinking. Certainly some of what they do is deduction, but syllogistic reasoning from general rule to particular case is not the particularizing skill that gives them their characteristic strength as clinical thinkers. Anyone in possession of those general rules can apply them to a given case, excluding and confirming the possibilities listed in the differential diagnosis. The construction of that list, however, requires a clinician. Someone well informed, well trained, and experienced is needed to describe the case and decide which rules may apply; only physicians, in other words, can construct the syllogism that the rest of us could work through so easily.

The rule for breast cancer is that firm, well-delineated abnormalities are the cancerous ones and, conversely, other kinds of lumps are usually benign.

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