Kathryn Montgomery’s classic text is even more relevant to medical education and practice today than when it was published a decade ago (originally in 2005). The author acknowledges the benefits of biomedical science but argues that clinical medicine is not a science but an interpretative practice. She points out a central paradox in medicine, the disparagement of anecdote, regarded as the lowest level of evidence. Yet it is the anecdote, a patient’s story, upon which the process of clinical medicine is based. Doctors work from the individual story, relating this to guidelines and their own clinical experience, returning to apply this to the individual patient in clinical judgement, which inevitably includes uncertainty. GPs are familiar with the challenge of this negotiation between the general and the particular.
In our society science is equated with rationality. However, clinical medicine is clearly different from a science and this has been recognised by conceding that it is also an art. However, Montgomery dismisses this duality and takes a middle path in describing medicine as a practice or, paradoxically, as a ‘science of individuals’. This view acknowledges the value of clinical experience and takes account of context in sound practical reasoning, or phronesis.
Montgomery asks whether it is possible to educate a ‘good doctor’ while recognising science as a tool rather than the soul of medicine. Medicine’s identification with science offers doctors an escape from emotion and the supposed perils of subjectivity. But this detachment has costs: a harsh medical undergraduate education, unnecessarily distanced clinical practice, dissatisfied patients, and disheartened doctors. Furthermore, it is evident that detachment from patients does not protect doctors from emotional pain but leads to an impoverished form of practice, eventually spilling over into the doctor’s personal life.
Montgomery argues that there is a place for emotions in rational judgements. The author dismisses a ‘friendship model’ of the doctor–patient relationship but advocates the doctor acting as a ‘good neighbour’, in an effort to rehumanise medical practice.
- © British Journal of General Practice 2018