Evidence and judgement: the scientific and the humane in the good doctor

There is a widespread view in medicine and amongst the general public that modern medicine is primarily a scientific enterprise and that the activities of clinicians rest on a secure basis of evidence-based science. As a clinician with a first degree in the arts, I have felt instinctively that this was not wholly the case. This thesis will examine the scientific nature of medical practice, identify and analyse what else is required, apart from science, for someone to be a good doctor, and suggest ways in which these additional attributes might be developed in medical education. I shall begin by examining the scientific evidence-base of medicine. It will emerge that there are three aspects to medical science: firstly, systematic knowledge of the systems of the body and their pathology, secondly, qualitative research, and thirdly, randomised controlled trials. Of the three only the first is truly science, but since science is a large family, the randomised controlled trial and qualitative research can be seen as members. Assuming, therefore, that there is some kind of evidence-base for contemporary medicine, I go on to ask how this evidence-base is modified in clinical practice. It emerges that there are a number of important modifications. Firstly, evidence must be individualised to the specific patient in the same way as a detective uses evidence in his investigation of a particular case. Secondly, doctors draw on wider sources of information than just the scientific evidence-base when they are treating patients. For example, patients' anecdotes and stories about themselves and the origins of their complaints are an important source of information in constant use. Thirdly, all the information in use by doctors is interpreted by them in the light of their knowledge of the individual patient and the patient's views must be sought on treatment decisions in the form of consent