Friday, May 05, 2006

JAMA reviews book on clinical judgment-"phronesis"

There is a favorable book review in the May 3,2006 issue of JAMA regarding what seems to be a very interesting book titled How Doctors Think: Clinical Judgment and the Practice of Medicine by Kathryn Montgomery. Dr. Montgomery is a professor of bioethics and medical humanities at Northwestern University.

One of her main themes is that clinical medicine is not a science.Even though I wonder if that statement is a straw man (I have always considered science as only part of medical practice as is implied when we talk about about the art and the science of medicine),there are a number of insights quoted in the review-enough to motivate me to order the book.

I quote from the review:

"Rather than considering medicine a science,she proposes that it be conceptualized as a rational,science-using practice.She draws on phronesis-the flexible interpretive capacity that enables moral reasoners to determine the best action to take when knowledge depends on circumstances-to characterize physician thinking in the clinical encounter as interpretive practice. In clinical medicine, this interpretive practice is displayed as clinical judgment which enables physicians to combine scientific information,clinical skill, and collective experience with similar patients to make sense of the particulars of one patient's illness and to determine the best action to take to cure of alleviate it."

"Clinical judgment done well is the intuitive and iterative negotiation of the patient's narrative of illness...This focus come with experience"

Aristotle spoke of the virtues of the ordered mind as including sophia (wisdom of first principles),episteme (emperical knowledge, techne (technical knowledge) nous (intuition) and phronesis (practical wisdom or prudence).

The evidence based medicine era with its emphatic focus on episteme and techne may foster the illusion that good clinical practice can be encapsulated in guidelines and pathways and that quality lies in obedience to them but it is the blending of those elements of science and technique with practical wisdom that makes good practice.

While Aristotle may have been bit harsh on the young the following quote captures the thought well that the particulars must sharpen the broad outline and abstractions of the "universals" that might correspond to the general clinical rules or guidelines and give them operational meaning tailored to the facts at hand:

"Whereas young people become accomplished in geometry and mathematics, and wise within these limits, prudent young people do not seem to be found. The reason is that prudence is concerned with particulars as well as universals, and particulars become known from experience but young person lacks experience, since some length of time is needed to produce it."
(Nichomachean Ethics)

1 comment:

Donna said...

Retired Doc,

Thank yo so much for your post on Phronesis. As and older but unretired nurse, with over 30 years of experience in a number of settings, and states, I am intrigued by the idea that there may be a way to take some of the "phronetic" wisdom of nurses who have "saved the day" for their patients, and to catalog their thoughts, and rememberances of their experience, finding themes... A very long way of saying, I want to help younger nurses learn more quickly than we did how to most effectively use nursing assessment and judgement to get people the help they need. Perhaps my motivation is to survive the future interactions I might have with the various health care systems that so often interact with elders.... smile
As I am quickly becoming one of them!
Thanks so much, for your interesting post.
If you have any MORE insight for me about this topic, I would enjoy hearing your thoughts.