Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0019
E. Montgomery
{"title":"A Calling to Be Better than Ourselves","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0019","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0019","url":null,"abstract":"It is difficult to name a profession with great authority with so little accountability compared to physicians who have finished supervised training. US Supreme Court justices have lifetime appointments and removal from office is exceedingly rare, nevertheless they are always under the public eye. Analyses demonstrate that the threat of malpractice is a poor tool at best to enforcing best practices. Attempts to establish peer review when used rarely address issues of medical reasoning. Furthermore, the physician shortage often leads to perhaps excessive tolerance for physicians’ actions. Accountability is a clinician’s ethical responsibility by virtue of the ethical principles of respect for autonomy, obligation to beneficence, avoidance of maleficence, and justice. These principles underlie the informed consent that is the basis of the clinician–patient relationship. In the end, it is only the personal commitment of the clinician to the patient that best guarantees that both will be served well.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"90 ","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"120874114","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0016
E. Montgomery
{"title":"Irreproducibility in Biomedical Science","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0016","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0016","url":null,"abstract":"Widespread irreproducibility of biomedical research has raised concerns. Journal editors and grant administrators are calling for greater safeguards. The causes go far beyond fraud, lack of transparency, and poor statistical analyses, as commonly thought. The root cause may stem from the same epistemic issues that confront medical reasoning, the necessary use of logical fallacies. However, the use of these fallacies increases the risk of uncertainty and subsequent irreproducibility. Furthermore, many procedures in data analysis actually result in an irretrievable loss of information by the Second Law of Thermodynamics as Applied to Information, thereby increasing the risk for irreproducibility. The second law holds that any irreversible process, such as operating only from the central tendency, as in the mean of a sample, results in a loss of information about the actual sample. The loss of that information makes the study less informative about the management of the individual patient.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115883206","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0006
E. Montgomery
{"title":"Evolution of Medical Reasoning","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0006","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0006","url":null,"abstract":"The challenge to certainty in the face of enormous variability generates an epistemic conundrum. The response to this conundrum has driven the evolution of medicine. The rationalist/allopathic tradition holds that an economical set of principles and facts exists from which each patient’s unique situation can be constructed. There are striking parallels between the allopathic tradition and science. Indeed, it was the ascendency of biomedical science that enabled allopathic medicine to triumph over competitive schools of medicine, such as the empirics in the form of homeopaths. The ascendancy of scientific medicine that allopathics claimed is now institutionalized. However, such economization risks the inverse problem in that there may not be any unique explanation for a particular disease phenomenology, thus giving rise to the possibility of misdiagnosis and mistreatment. Nonetheless, the rationalist/allopathic tradition follows from Aristotle’s metaphysics translated into medical terms by Galen, whose influence is still felt.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"93 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132519762","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0018
E. Montgomery
{"title":"Critique of Practical and Clinical Medical Reasoning","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0018","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0018","url":null,"abstract":"A distinction is made between “scientific” medicine and practical medicine. The former relates to medical decisions couched in scientific methods such as the hypothetico-deductive approach, and it is often used pejoratively, as excessive reliance on such science and scientists, particularly if the scientists are not also clinicians. Practical medicine suggests alternatives, intuition. To be sure, successful medical reasoning has long predated the development of modern science that supports the notion of scientific medicine. Furthermore, some physicians just seem better without necessarily having greater scientific knowledge. Ethics is fundamental to medical decisions. The distinction between scientific and practical may not be very sharp, and trying to separate and advance one over the other likely is counterproductive. Modern allopathic physicians pushed the distinctions, as seen in their code of ethics and the changes subsequent to the Flexner Report. Critical analysis of intuition suggests that it is “scientific” and that science is “intuitive.”","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"45 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125173109","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/MED/9780190912925.003.0004
E. Montgomery
{"title":"Medical Epistemology","authors":"E. Montgomery","doi":"10.1093/MED/9780190912925.003.0004","DOIUrl":"https://doi.org/10.1093/MED/9780190912925.003.0004","url":null,"abstract":"Deductive approaches in medical decision-making have an air of certainty borrowed from philosophical deduction, as for example, in the hypothetico-deductive approach. However, deduction, although certain, is limited because it cannot contribute to new knowledge other than proving some claims to knowledge as false (using modus tollens). Syllogistic deduction requires modification to gain utility, such as the partial and practical syllogisms. However, these forms are logically invalid in that they do not ensure certainty in the conclusions. The partial syllogism can be rendered more certain by the use of probability. However, the necessity of a medical decision requires dichotomization of the continuous probability variable. A cutoff threshold applied to the probability is necessary to enable a dichotomous decision, such as whether to treat or not treat a patient. The practical syllogism introduces the notion of cause and effect, which also may influence medical decisions, although often in a counterproductive manner.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"25 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126051908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/MED/9780190912925.003.0008
E. Montgomery
{"title":"The Meaninglessness of the Mean","authors":"E. Montgomery","doi":"10.1093/MED/9780190912925.003.0008","DOIUrl":"https://doi.org/10.1093/MED/9780190912925.003.0008","url":null,"abstract":"The mean (average) or other central tendencies of a set of data is an internal construct that does not necessarily reflect reality. It is possible to determine the central tendency from any arbitrary collection of data as long as they vary on the same dimension. Even if applied to a relevant sample of data, the central tendency may be a poor reflection of data. A virtually infinite number of different collections of data may have the same central tendency and variance. This has very important implications when reasoning from studies reporting means and standard deviations. The same concerns apply to medians as the central tendencies and quartiles as the variability. When translating studies to the individual patient, the cumulative percentage (probability) function may be more helpful. There is a strong inclination to attribute some ontological status (reality) to measures of central tendency that can be misleading.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"108 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122691960","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0013
E. Montgomery
{"title":"The Role of Metaphor","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0013","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0013","url":null,"abstract":"Metaphor use in medical decisions and research is ubiquitous. Use of treatments for “off-label” indications follows as a metaphor to approved indications. Fundamentally, reasoning from a sample of patients in a clinical study to an individual patient is a form of metaphor. Hypothesis generation for hypothetico-deduction medical decisions and for the scientific method often arises from metaphors. However, metaphors are the Fallacy of Pseudotransitivity, which risks the Fallacy of Four Terms. The associated risks can be estimated from the epistemic risk in terms of epistemic distance and epistemic degrees of freedom. Metaphors can be nonlinguistic, and a particular form is the process metaphor. The source domain to explicate the target domain is a process that may never be fully realized, and thus the certainty of the metaphor stems from the process itself. Examples of process metaphors include allopathic reductionism, scientific reductionism, the Large Number Theorem of statistics, and others.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"22 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115019547","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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