Clinical Judgement: Evidence in Practice (Oxford Medical Publications) [Paperback]

R. S. Downie (Author), Jane MacNaughton (Author), Fiona Randall (Author)

Book Description

Publication Date: April 27, 2000 | ISBN-10: 0192632167 | ISBN-13: 978-0192632166 | Edition: 1

Medical decisions are usually thought to follow from evidence-based science, but this is an oversimplified view. The book investigates the complex nature of evidence in medicine, makes a case for the centrality of clinical judgement, and identifies the elements of good judgement in decisions made in the clinic, in public health, and in resource management. - ;There is a widespread view that modern medicine is primarily a scientific enterprise and that the decisions of clinicians follow from evidence-based science. In terms of this view the need for clinical judgement is minimal. The aims of this book are to make a case for the centrality and irreplaceability of clinical judgement, to identify the elements of good clinical judgement, and to suggest how these might be developed by using the humanities in medical undergraduate and postgraduate education. The authors argue that good clinical judgement requires both technical evidence and a humane attitude. But technical evidence is not always quantifiable or even scientific; it can be like that of the detective or the literary scholar. A humane attitude involves ethical sensitivity, but also a broad educated perspective which can be derived from the arts. The authors illustrate their argument by examining decisions made by doctors in clinical situations, in public health, and (in a chapter contributed by a hospital consultant) in resource management. About the authors: Robert S. Downie is Professor of Moral Philosophy at Glasgow University since 1969. He is a member of the BMA Ethics Committee and co-editor of the Journal of Medical Ethics. He has published extensively in the field of medical ethics. Jane MacNaughton has recently taken the position of Director of Centre for Arts, Humanities, Health and Medicine at the University of Durham. Previously she was Clinical Lecturer in General Practice at Glasgow University and a part-time GP. - ;. . . [A] well-written book . . . lucid discussion of the relation between science and art in clinical medicine . . . I was so impressed with the clarity and intelligence . . . of this book. - The New England Journal of Medicine;This slim well-written book deserves a place on the shelf of anyone who wishes to be a well-rounded, complete physician as well as those training the next generation of doctors. - Karyn Baum, University of Minnesota, USA

Editorial Reviews

From The New England Journal of Medicine

In simpler times, this short, well-written book would have warranted praise for its lucid discussion of the relation between science and art in clinical medicine. The central thesis is that physicians use both scientific evidence and clinical judgment in every aspect of their professional lives, whether they are engaged in research or clinical practice. Although this assertion may not seem startling, the authors' dissection of the qualitative differences between medical research and clinical practice is full of insights and wonderful examples that make the book a pleasure to read.

But these are not simple times, and to the authors' credit, they have gone beyond making the case that evidence and judgment form a "seamless garment" for physicians. They have also examined how this garment stands up to challenges that seem (at least superficially) unique to our times, including the need for the promotion of public health, the rationing of medical services, and the rise of consumerism. For most of these challenges, the authors' discussions are convincing.

The authors' perspectives are articulated in early chapters that are a delight to read. They examine the apparent tension between medical research, which is concerned with providing generalizable systematic understanding, and clinical practice, which is concerned with the human being who happens to be in front of the physician. Researchers, they note, seek to isolate the effects of single factors, whereas physicians in practice must use clinical judgment to weigh the effect on individual patients of numerous variables, many of which are not physiologic in nature. Although anecdotal evidence is viewed scornfully by researchers, it is an important source of learning for physicians and their patients.

The "complete physician" can apply evidence from research and personal experience with judgment and compassion in the care of individual patients. In later chapters, the authors make a good case that the same synthesis of knowledge and skills is needed in the pursuit of public health and in the rationing of medical resources. Dr. Fiona Randall has contributed an excellent chapter on medical resources that examines physicians' objections to rationing. She asserts that physicians focus on their role as advocates for their patients, but they tend to ignore their role as trustees for the overall pool of resources. There has been little success with insurer-imposed criteria for the "microallocation" of resources -- that is, decisions regarding individual patients aimed at optimizing both quality and efficiency. Thus, she concludes, physicians must use their clinical judgment to guide the allocation of resources in ways that reflect their obligations to their patients and as trustees on a broader scale.

One of the most important sections of the book is its discussion of the threat of consumerism to "the humane doctor." The authors note that this threat is particularly insidious, since many physicians embrace consumerism as a trend that seems enlightened and respectful of their patients. In one interpretation that few would challenge, the patient-consumer has the right to refuse any treatment. However, the flip side of this right is the ability of the patient-consumer to receive any treatment that he or she might demand. A customer can buy a pair of shoes, even if they do not fit. Can a patient who is willing to pay with personal funds require a physician to perform tests or provide treatments that are not consistent with good practice?

There are, as the authors observe, many physicians and patients who prefer the ethics of consumerism to those of professionalism. The doctor-patient relationship is, after all, an unbalanced one in which physicians have more power as well as more responsibility. Carried to its logical conclusion, the trend toward consumerism will cause medicine to become a service industry rather than a profession. In that context, the ethics of medicine may be replaced by the discipline of the marketplace.

If this book disappoints at all, it is in its failure to plunge more deeply into this abyss. The authors note that the perception of these changes as a threat may be tendentious and that the rise of consumerism can be viewed as a cultural change, perhaps a desirable one. They write: "If it is desirable, then the idea of the humane doctor must be replaced by that of the doctor as a supplier of goods and services. We do not think the change is desirable and so we shall continue the analysis of the humane doctor."

I was so impressed with the clarity and intelligence of the rest of this book that I was disappointed to discover that the authors were not going to provide the expected discussion of the ways in which the humane doctor can adapt to consumerism. This question is an extremely difficult one, of course, but of great importance. The trend toward consumerism seems as powerful as the need to control resource use -- and, as long as the global economy remains strong, consumerism may even dominate efforts to ration care.

Thomas H. Lee, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Review

The book stimulates intellectual curiosity by weaving lessons in history, philosophy, ethics, the arts and humanities into hypothesis to be dissected and challenged in a lively classroom. Education for Health

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Product Details

• Paperback: 216 pages
• Publisher: Oxford University Press, USA; 1 edition (April 27, 2000)
• Language: English
• ISBN-10: 0192632167
• ISBN-13: 978-0192632166
• Product Dimensions: 8.4 x 5.4 x 0.5 inches
• Shipping Weight: 8.5 ounces (View shipping rates and policies)
• Average Customer Review: 5.0 out of 5 stars  See all reviews (1 customer review)
• Amazon Best Sellers Rank: #3,252,303 in Books (See Top 100 in Books)

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3 of 3 people found the following review helpful:

5.0 out of 5 stars A real gem, March 25, 2001

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"hcollin" (Guayaquil, Ecuador) - See all my reviews

This review is from: Clinical Judgement: Evidence in Practice (Oxford Medical Publications) (Paperback)

This book is a real gem for anyone involved in taking clinical decisions. It is rare enough to find literature on good medical judgement, let alone books on medical philosophy and ethical reasoning that are presented in such a pragmatic and readable way. Especially amidst the widespread vogue of evidence based medicine, this book fills a wide gap between factual science and patient-oriented clinical analysis. Indeed, bearing in mind that physicians deal with patients, not with diseases, this book also presents a uniquely humane viewpoint to everyday decisions regarding patient care. It covers the elements of clear and effective judgement, from science, in general, to the clinic, in particular. But Downie and Macnaughton can't hide the fact that it is written in a scholarly way and is thus meant to be read in a stepwise, cover-to-cover continuum. It is directed to both pre- as well as postgraduate students, but I feel that undergraduates would do themselves (and especially their future patients) an enormous favor by reading it thoroughly early in their careers.