Ockham’s Scalpel

Now in my first year of medical school, I am reminded of the last time I learned a new methodology. I was a first-year student at a liberal arts college and decided to enroll in introduction to philosophy. We had read a few seminal works in our required freshman humanities seminar, and I had enjoyed contemplating ‘idealism versus realism’ and ‘identity and difference’—conceptual frameworks previously unknown to me.

Reading philosophy, I soon learned, however, was very different from practicing it.

Did we sit around asking, ‘What is death?’ and ‘How do I what I know?’ Yes!  Were we wearing thick-rimmed glasses and black turtlenecks? If we hadn’t been in Southern California, probably. Our professor framed the dominant positions in metaphysics, epistemology, and ethics, and he took time to explain the basic principles of logic. An argument was composed of at least two premises and a conclusion that followed by logical necessity. When evaluating the quality of an argument, we were not to say ‘good’ our ‘bad’, but rather that a premise was ‘valid’, and an argument was ‘sound’. There was to be nothing extraneous to the argument, or no statements, which were unsupported by the premises contained therein.

Our first philosophy paper was to be written in the first person—we were instructed to start with a brief outline, make a logical argument (premise, premise, conclusion format), foresee a possible objection, formulate a counter-objection, and offer a second objection to this counter-objection.

In my first paper I challenged Richard Dawkins’ claim that faith is like a virus of the mind.[1] The analogy failed, I argued, because it was rooted in assumptions about viruses that were unsupported by relevant examples like herd immunity. I applied what I had learned about viral transmission in biology class to ground my argument. When the paper was returned to me with a marginal grade, my professor explained that my argument was unsound. He encouraged me to rewrite it suggesting that I avoid abstract terms, forego examples drawn from personal experience, and apply any terms I used consistently. Within these rigorous limits, less was more; every word required a rationale for its presence and every sentence its placement. I could no longer get by on cleverness and a sizeable vocabulary.

In medical school, first year gross anatomy has a reputation for being a rite of passage. We not only encounter the body in the abstract of the lecture hall, but also in the flesh of the donor on the dissection table. We master new terms and our knowledge is transformed by the very sensory experience of the laboratory.

A course called Foundations of Clinical Medicine, however, is where we really learn what it means to be a doctor—to embrace the age-old conventions of the physician-patient relationship thoughtfully redefined for the present. It is here, in Foundations, that we are introduced in formal terms to what I consider to be the phenomenological crux of medicine—the clinical encounter.

At Columbia, we are taught both process and content, but we begin with process, since content will take years to grasp fully, and it’s a process that will follow us through our training regardless of specialization. The first step in the clinical encounter is to enter with respect, define our role, and ask a patient’s permission. Secondly, we are to use open-ended questions to elicit the chief concern and listen actively, summarizing intermittently to ensure we understand correctly. At this stage, we try to dispel any expectations about the patient or her condition that might color what we are hearing—our goal is to be as curious and open in our listening as in our questioning.  In the third step we perform a physical exam if called for, flesh out the patient’s medical history, and clarify points that lead to a preliminary diagnosis, before summarizing the visit and discussing next steps.[2]

If you’ve been to the doctor’s office, this method sounds intuitive—but at its heart is a radical dialectic. The encounter requires that we modulate our demeanor to align with that of the patient and suppress affect except to express care and respect in order to foreground the patient and his or her bodily and psychological experience. The second step of reflective listening, in particular, demands that we momentarily bracket clinical knowledge and pattern recognition to meet the patient with full and unmediated attention. Of course, the dialogue that ensues does not much resemble a logical argument, but like the act of writing my first-year philosophy paper, which also proceeded in a four-step fashion, my goal during the interview is to communicate with restraint, consistency, and disregard for presuppositions in order to gain information relevant to the patient’s care. I speak in my own voice, but it is constituted through relation.

In order to practice the clinical encounter, we wear our short white coats, stethoscope, and nametags and knock on the door of an exam room in our campus’ Simulation Center. This time it’s a standardized patient, or an actor trained to interact and provide feedback, sitting on the exam table. Our preceptor or classmates are just outside, observing through a one-way window. In the beginning, it feels like acting: there is a formal simplicity in the pared-down quality of the encounter. Although removed from the exigencies of illness and aging, the heart still races.  Do we fear failure in our practice to master structure, establish tone, and elicit pertinent information?

I don’t know that my classmates have considered how the methodology we’re learning now to become clinicians is different from our past lives in the basic sciences, social sciences or the humanities. What I do know is I’m glad for my philosophy training.

After my first D paper, I persisted. I came to enjoy the rigor and versatility a logical toolkit afforded—I could probe questions like ‘What is the good?’ and did not know what conclusion I would come to until I had unpacked my assumptions, scrutinized premises, and in the slow, time-consuming process of thought, while swimming or walking to and from class, formulate an argument. Since then, my philosophical practice evolved to approach complex ontological and ethical questions; nonetheless, my point of departure was always direct language and a sound argument.

Now, when I approach a clinical encounter, I ask myself, Can I say less, so that the patient can say more? Given time limits, What is necessary? And what is extraneous? Today, it’s a standardized patient. Soon it will be a real one.

Catherine Parker is an M.D. candidate at Columbia University Vagelos College of Physicians & Surgeons. She holds a B.A. in French Studies and Philosophy from Scripps College in Claremont, California, and an MPhil in European Literature and Culture from Cambridge University.

[1] “Dawkins, Richard. “Viruses of the Mind” Dennett and His Critics: Demystifying Mind. Ed. Bo Dahlbom. Hoboken, NJ: Wiley-Blackwell, 1995.

[2] This is a brief summary of the “Compass Model” developed by Drs. Mike Devlin and Delphine Taylor at Columbia University Vagelos College of Physician and Surgeons as part of the Foundations of Clinical Medicine course taught to first-year students.

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