Ludwik toresminho

ABSTRACT The differential selection and assessment of knowledge is a key feature ofmedical practice. This paper presents a study of how doctors select and assessinformation in practice. Fourteen internal medicine professors from a relevantmedical school in Rio de Janeiro, Brazil, were selected through preliminary interviewswith medical students. The professors were subjected to open-ended interviews. Theresulting material was interpreted through a conceptual framework derived fromLudwik Fleck, in order to establish the relevant elements of the thought stylecharacteristic of the way they select and acquire new knowledge. The thought stylethat emerged from this set of interviews can be briefly characterized as a largelyintuitive, pragmatic, result-oriented search of relevant (that is, potentially useful inpractice) information. The doctors sought sources with academic credibility, but theymaintained primary interest in practical, experiential knowledge. They also expresseda rather sceptical stance, at times bordering on cynicism. Despite this mistrust,doctors lack the resources (time, knowledge of technical aspects of research,particularly in terms of epidemiology and statistics) to effectively assess knowledgethat is constantly being force-fed to them. This relative lack of resources is worsened,on one side, by the perception of medicine as subject to frequent and major changes,and on the other by the vastly disproportionate forces available to those whoeffectively produce and distribute such knowledge.

Keywords epistemology, medical anthropology, medical knowledge, thought style

The Thought Style of Physicians:

Strategies for Keeping Up with MedicalKnowledge

Kenneth Rochel de Camargo, Jr

Cognition is therefore not an individual process of any theoretical ‘partic-ular consciousness’. Rather it is the result of a social activity, since theexisting stock of knowledge exceeds the range available to any oneindividual. [Ludwik Fleck (1979): 38]

Although it would be far too simplistic to assume that knowledge is the soleor even the ultimate determinant of actual medical practice, the ‘existingstock of knowledge’ (as in Fleck’s epigraph) surely plays a major role in thisregard. Much of what a physician does can be described in terms ofmaking decisions based on trusted knowledge that (s)he is constantlyupdating. This means selecting specific items from a plurality of sources,and also differentially evaluating their relevance and intrinsic merits. Itthus follows that assessing the validity of certain statements concerning

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medical knowledge is an integral part of medical practice; this is clearly anepistemological enterprise.

Before proceeding, a cautionary remark has to be made. Giving aprecise definition of what ‘knowledge’ means depends on the underlyingphilosophical framework of choice. The Cambridge Dictionary of Philosophy,for instance, ties such definition to a discussion about epistemology [Audi(1999): 273–75], whereas Ian Hacking includes it in his list of ‘elevatorwords’ – that is, words that are made to work at a higher level than thoseused to describe facts and ideas, and which are usually circularly defined[Hacking (1999): 22–23], and Fleck, finally, simply uses it without bother-ing to define the meaning. In order to avoid the potential pitfalls of such acomplex discussion, knowledge in this text is equated to the cognitivecontent acquired from formal education, professional practice or techno-scientific literature.

This paper is a report of a qualitative, exploratory study whoseobjective is to answer the following questions: what are the strategies thatdoctors deploy in order to keep up with the development of medical knowledge,particularly in selecting what can be trusted; and how well prepared are they todo it?

This is a key issue with repercussions in several areas of research andpublic policy, such as the quality and costs of medical care; the incorpora-tion of new technologies in current practice; and the emergence anddiffusion of innovation in medicine. Regardless of its importance, however,this is an aspect that remains relatively under-researched. Most of the workhas been done by epidemiologists, particularly those gathered under theself-designated label, ‘Evidence-Based Medicine’ (EBM). Their goals,however, are clearly normative [see, for instance, Christakis et al. (2000)] –that is to say, their primary interest is to establish how it should be done,rather than how it happens in practice.

A notable exception to the above rule is the work of cognitive scientists[see, for example, Allen et al. (1998)], who nevertheless are concernedwith slightly different aspects than the investigation reported here; inparticular, the specifically epistemological aspects of medical reasoning,which is a key issue for this work, are usually left aside.

Conceptual Framework

Ludwik Fleck’s comparative epistemology [Fleck (1979)] offers a uniqueset of tools to look at the production and circulation of knowledge incontemporary societies, especially when related to the biological sciencesand medicine. The following lines will present briefly some highlights of histheoretical developments.1

Two concepts stand at the core of Fleck’s comparative epistemology:the ‘thought collective’ (Denkkollektiv) and ‘thought style’ (Denkstil). Hedescribed the first as . . .

. . . a community of persons mutually exchanging ideas or maintainingintellectual interaction, we will find by implication that it also provides the

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special ‘carrier’ for the historical development of any field of thought, aswell as for the given stock of knowledge and level of culture. [Fleck(1979): 39]

and the second as . . .

. . . a definite constraint on thought, and even more; it is the entirety ofintellectual preparedness or readiness for one particular way of seeing andacting and no other. [Fleck (1979): 64]

It must be stressed that the thought style is not an optional feature that canbe wilfully, consciously chosen, but rather an imposition made by theprocess of socialization represented by the inclusion into a thought col-lective.2 It should also be noted that although ‘style’, like Kuhn’s‘paradigm’ has the kind of semantic fuzziness that allows for all sorts ofabuses, it is nevertheless Fleck’s word of choice, and I am using it in thesense of his precise definition.

Fleck distinguishes two major areas within a thought collective inmodern science [Fleck (1979): 111–12], one comprising the experts thatactually produce knowledge, which he calls the esoteric circle (he furtherdetails this region, describing the inner circle of the specialized experts andthe outer of general experts), and the other consisting of the ‘educatedamateurs’, the exoteric circle. This epistemological topography allows thedistinction between different forms of communication [ibid.: 112]: expertscience is characterized by journal and vademecum (or handbook) science,the first representing the intense, fragmentary, personal and critical dia-logue within a given field of knowledge, and the second a synopticorganization of the former [ibid.: 118]; the exoteric circle is fed throughpopular science, which is ‘. . . artistically attractive, lively, and readableexposition with last, but not least, the apodictic valuation simply to acceptor reject a certain point of view’ [ibid.: 112]. Finally, introduction to theesoteric circle – which Fleck compares to a rite of initiation [ibid.: 54] – isbased on yet a fourth type of scientific text medium, the textbook [ibid.:112].

These elements allow for the construction of a geography of anintellectual field, describing not only peoples and places, but also theinterchanges taking place between them. I do not intend, however, toascribe more value to such objects than that of a convenient notation –turning Fleck’s model into an ontologically founded account would, in asense, be going very much against the very gist of his ideas.

All medical institutions (including public health, health care andmedical schools), as well as medical knowledge and practice, are per-meated by a specific thought style. This does not mean that medicine is ahomogenous epistemological region. Science itself can hardly be describedin general terms, being divided into different kinds of scientific practice,which configure different cultures, according to Knorr Cetina (1999). Thisis further complicated in medicine since its mainstay is not the productionof knowledge, but its application in a variety of situations according to

Rochel de Camargo: Thought Style of Physicians 829



ethical principles [Canguilhem (1978): 134]; even though a description ofa medical style of thinking can be sketched [see, for instance, Fleck (1986);Bates (2000); Luz & de Camargo (1997)], it should not obfuscate theextreme differences within that field. This might pose an obstacle forutilizing Fleck’s framework – in effect, any epistemological framework – toanalyse the knowledge of practitioners, rather than researchers. It shouldbe noted, however, that there is nothing in Fleck’s definitions of a thoughtstyle and a thought collective that specifically ties them to communities ofresearchers – in fact, he refers to the world of fashion in order to exemplifythe general structure of a thought collective [Fleck (1979): 107–08].Additionally, in a pre-Genesis paper [Fleck (1986)], he describes what heviews as specific features of the medical ‘way of thinking’, an expressionthat can be seen as a step along the road of the development of the conceptof a thought style. That text dwells quite extensively on the differencesbetween the medical and the scientific ‘ways of thinking’. Taking suchdifferences into account, as well as the idea that in complex societies thereare ‘multiple intersections and interrelations among thought collectives’[Fleck (1979): 107], one can conceive of at least two distinct thought stylesin biomedicine: researchers’ and practitioners’. There is, however, a widearea of overlap between them.

Anthony Giddens [(1990): 27] described how lay people rely on whathe calls expert systems in everyday life, meaning the myriad of technologiesthat we interact with on a daily basis without really having a firm grasp onhow they work; he goes so far as to describe this trust in terms of faith,exercised in a pragmatic way. Given the complexity of modern industrialsociety, this means that everyone is a ‘lay person’ in many areas [see alsoKnorr Cetina (1999): 6–7]. Expert systems also exist in medicine, and atleast some of them are as unreachable to regular doctors as to lay persons,although the former may be exposed to those systems through theirauthoritative, ‘textbook science variety’, version. This does not mean thatdoctors’ access to journals and all sorts of papers during their careers willbe blocked, but it does mean that they might lack the necessary skills toeffectively interpret what is omitted and compressed in these papers. In acommentary that parallels Fleck’s remarks on the same subject, AllanYoung illustrates this point by drawing an analogy between scientificliterature and Conan Doyle’s stories of Sherlock Holmes:

. . . there is a growing literature dedicated to the rhetoric of scientificwriting. A favourite argument of these authors is that, when scientistswrite journal articles, they erase the boundary between real time (con-tingent, undetermined) and narrative time (logical, causal). The erasure isachieved through rhetorical conventions, such as the use of passive voice(‘results were obtained’) and the absence of any reference to humanagency (no personal pronouns). My impression is that, despite thesedevices, competent readers of scientific journals can tacitly recognize theco-existence of the two kinds of time – real/contingent and narrative/determined – in the work they read. On the other hand, in popular sciencemagazines, erasure is attempted through other means: original reports areaggregated, renarrated and oriented to a shared telos (a notable scientific




‘discovery’). Non-scientist readers of these magazines are analogous tothe readers of Watson’s accounts, in that they seem inclined to mistakenarrative time for real time. [Young (1995): 357]

Extrapolating from Young’s distinction, my contention is that physiciansare ‘competent readers of scientific journals’, only to a limited extent.Since they lack adequate contextual information, they are unlikely to beable to unravel the two kinds of narrative in scientific papers, and are morelikely to take statements at face value.

Modern medical knowledge and practice draw from a variety oftheoretical/technical sources, from quantum mechanics (the basis of themost advanced imaging methods) to molecular biology, filtering themthrough several techniques of assessment and validation, which are part ofanother discipline, epidemiology, which in turn relies heavily on mathe-matical – more specifically, statistical – tools in its trade. None of theseareas of knowledge is the intellectual province of the practising physician;in Fleck’s terms, the latter are at most part of the exoteric circle of thethought styles of those areas. This brings back the question posed atthe beginning of this paper.

The process of schooling that turns the medical student into a fully-fledged medical doctor is an organized inculcation not only of certaincognitive contents but also of a distinctive way of defining what ‘reality’itself is [Atkinson (1997); Good (1994): 65–87]. This learning is integratedinto a system of opinions that, once again according to Fleck, resistchallenges tenaciously, creating what he described as ‘the harmony ofillusions’ [Fleck (1979): 27–38]. An essential part of that thought style is aset of criteria that identifies trustworthy knowledge, usually identified as‘true’, ‘objective’ and ‘scientific’, according to what Good dubbed bio-medicine’s ‘folk epistemology’ [Good (1994): 8–10]. Indeed, claims to thefirm rooting of biomedicine in scientific knowledge are widespread, as canbe witnessed in the introductory chapters of clinical handbooks [see, forinstance, Barker et al. (1999); Isselbacher et al. (1994); Kassirer &Kopelman (1991)], or in popular science books expressly dedicated todispel any ideas that medicine might not be grounded in science [forexample, Weatherall (1995)]. The abusive use of the word ‘scientific’ andthe counterpart expression ‘not scientific’, however, has been noted at leastby one author [Brewin (2000): 586], who wrote: ‘Why not choose plainerwords like abundant or scanty, convincing or unconvincing, objective orsubjective?’

Assessing criteria for the selection of trusted knowledge poses aproblem in terms of Fleck’s original work. Whereas he used scientific textsas the basis for his analysis, in order to understand how doctors evaluateknowledge the starting point cannot be the texts themselves, since thethought style determines which texts are read, how they are read, and how(or if) they are incorporated into the available stock of knowledge. Adifferent approach is thus required. Given Fleck’s description of a thoughtstyle as a definite constraint on thought, its characteristics should also be




present in other forms of discursive production,3 as speech itself. In thisregard, the meaning of certain words currently used in appraising theknowledge presented in textual materials, such as ‘science’, ‘scientific’,‘proven’, ‘fact’, should provide an important insight into this thought style.In order to understand this meaning, it is necessary, according to Wittgen-stein [(1997): 39, paragraph 83], to play the language game where suchmeanings make (or gain) sense. In other words, it is necessary to interactand talk to people who are part of that thought collective. How to talk, andto which people, are issues that will be dealt with in the description of themethodology of this study; what remains to be seen in this section is how toreconstruct such meanings once the pertinent data is gathered.

Methods

In order to gain access to the language games of my subjects, I decided touse interviews as my main methodological instrument [for an in-depthreview of the methodological and theoretical issues related to interviewingtechniques, see Fontana & Frey (2000)]. It should be noted that the useof interviews in this context is not based on the realist assumption that‘. . . interview responses index some external reality’ [Silverman (2000):823], but rather on a narrative approach, where ‘. . . we open up foranalysis the culturally rich methods through which interviewers and inter-viewees, in concert, generate plausible accounts of the world’ [ibid.: 823].Even then, it could be argued that perhaps a classic ethnographic studywould be a better approach.

I have three reasons for my methodological choice. First of all, I wouldsay that I sacrificed depth for breadth; given the available time for field-work, I would be able to study at most one ward in the hospital, and thus Iwould have had access to one, at most two, of my interviewees in theprocess, whereas I considered a multiplicity of interviewees to be im-portant for the study – the advantages of having multiple voices in acomparable study were stressed by Gilbert & Mulkay [(1984): 188].Second, it must be noted that, having graduated in medicine, I am part ofthe same esoteric circle, and thus at least minimally competent in thatlanguage. Although firsthand experience cannot be equated to a rigorousethnographic procedure, it certainly allows for an intimate knowledge ofthe field. My previous personal and professional experience served both ascontext for filling gaps and, at least to some extent, a measure of compari-son. Finally, as the results will show, much of the actual process ofselecting and incorporating new knowledge takes place in spaces otherthan the workplace, and a traditional single-site ethnographic observationwould leave these out.4

I interviewed medical school professors, because they are in charge ofthe reproduction of values in the profession. Additionally, those professorsare also usually respected doctors too, thus occupying a pre-eminentposition in the medical field. This meant that, in terms of language games,




at least three different kinds of interaction could be postulated beforehandin the context of this study: among clinicians; between these and medicalstudents; and finally between the clinicians and the interviewer – myself.Based on my experience, I consider the first two of these interactions as sointertwined in the clinical setting as to be part of an inextricable con-tinuum, and the third a mere variation within this continuum. In effect,with at least four of the subjects, this is a de facto situation and not anassumption; the interviews were indeed pieces of an ongoing conversation,for almost 20 years, about those same issues.

I chose one of the most traditional and respected medical schools inRio de Janeiro for the field research,5 which is also the medical schoolwhere I graduated. This choice was based on the assumption that suchfamiliarity would make the initial steps in the field easier, an assumptionthat proved to be correct with the unfolding of the research, although itbrought about other difficulties, which will be dealt with later in thispaper.

The next step was to choose which professors should be interviewed.First of all, I decided to choose internal medicine professors as interviewsubjects, rather than more specialized professors, since all students areexposed to internal medicine for long periods of time during their trainingin medical school. Medical specialists tend to teach short-term courses,thus having less exposure to the students and being less influential, onaverage, in the process of building the future doctors’ worldview.

In order to narrow the set of interviews further, the most respectedprofessors were identified. An assistant researcher, a medical student whojoined my research project, conducted a series of interviews with medicalstudents in the last three years of medical school (these students hadcontact with most, if not all, the internal medicine professors). Myassistant asked the students to identify the best professors, in their opinion.These interviews yielded a list of 18 names, among which were someUniversity hospital staff members who, although not professors in thestrict sense of the word – that is, not part of the medical school faculty –were considered as such by the students. It was not possible to interview 4of the 18 professors during the time frame of the study, for differentreasons (vacancies, study leaves, and so forth). This left 14 interviews,which provided the basis of this paper.6

The subjects were contacted in their workplaces at the Universityhospital, when the schedule for the interviews was arranged. Formalintroductions were unnecessary at this hospital, since I had previousacquaintance with all the subjects. All interviews took place in a relativelyquiet room near the wards in which the subjects usually worked, duringfree slots of their usually busy schedules. All interviews were taped, withconsent from the interviewee, and ranged in time from 35 minutes to anhour and 40 minutes (approximately). Both the initial contact and theopening of the interviews were standardized: I informed the subjects that Iwas conducting a study on medical teaching, and during the interviews




I asked three standard questions: what was the doctor’s academic back-ground; what, in her/his view, were the most important features in adoctor; and what would an ideal medical school be like. These questionshad no relevance in themselves, as they were designed to help set up ashared orientation to the questions that followed. As the interviews pro-ceeded, I would ask, for example, how they updated their knowledge, andhow they sifted relevant information from the overwhelming jumble thatmedical journals and, more recently, the internet, presented. If researchactivities were not spontaneously mentioned, I would ask about theirpersonal involvement with research, and/or the relevance that it would havein medical education.

Interviews always present the risk of inducing subjects to respond withwhat they would deem ‘appropriate’ answers, even if these did not actuallyrepresent their views. I chose this extremely indirect approach in order tominimize that risk.7

The resulting interviews were transcribed, and the text files werestored using a free software package called Logos, a textual database systemdeveloped in Brazil specifically as an aid to the analysis of unstructureddata [de Camargo (2000)]. Each interview generated a record in the file,which was analysed for the presence of recurring themes connected tomedical knowledge, practice and their relationship. Text chunks werecoded according to the presence of these themes, and then regroupedaccording to them. The choice to work with themes rather than specificwords is due to the fact that several different words can be semanticallyrelated, even if they are not exact synonyms, and because the goal of theresearch is to reconstruct a thought style, not a lexicon. The themes andthe textual groups thus produced are presented in the following section;original passages have been translated from Portuguese to English by me.As far as possible, I tried to preserve the fluidity and lack of formality of aspoken interaction while translating from Portuguese to English. What maylook at times like broken English is the result of a deliberate effort topreserve the spontaneity and even the awkwardness of the spoken lan-guage, instead of trying to ‘correct’ and thus sterilize it.8

Results

Characteristics of the Respondents

The interviewed subjects are listed in Table 1. Names have been replacedwith pseudonyms in order to preserve interviewees’ privacy.

A few characteristics of the group should be noted. First, there aremany fewer women than men in the group, probably reflecting the compo-sition of the faculty of the medical school. It is also of interest that thedistribution of time since graduation is heterogeneous, with aggregation insome periods; this reflects changing recruitment policies in the Universityover the years. The majority of the interviewees graduated from the sameschool, which is not an unusual situation in Brazil. None of them has a




doctoral degree other than the MD (although one of them has a qualifica-tion which is considered equivalent in Brazil to a PhD), and four of themhad not even a masters degree. This is also not unusual in medical schoolsin Brazil, especially in the clinical courses, although this situation has beenchanging in recent years; it should be noted that this group is betterqualified in this sense, anyway, than the bulk of the professors of the samedepartment (or comparable hospital doctors), and this may have had animpact on their teaching skills and thus their appreciation by the students.Conversely, it might be argued that these are more committed professors,who would be more likely to invest in an academic career, and would also bemore likely to receive better evaluations from their students. In any event, itis an outstanding group among their peers also from this point of view.

Recurring Themes in the Interviews

The process of coding the transcriptions of the interview process – in itselfan integral part of the analysis [Ryan & Bernard (2000)] – yielded sixrecurring themes in the interviews. For reasons of space, only one of thethemes – the second most frequent in the interviews, and undoubtedly themost relevant for the core issue of this paper – will be extensively presentedand analysed here; the other five will only be briefly commented upon. Thethemes are presented in Table 2.

TABLE 1Characteristics of the Respondents

Pseudonym Sex Year grad Inst stat Other degree School egress

Alberto M 1965 professor ‘livre docência’ noAlexandre M 1974 physician master yesCarla F 1992 professor residency yesCelia F 1984 physician mastera noCelso M 1968 professor master yesJorge M 1983 prof/phys mastera noLauro M 1959 professor none yesLuis M 1984 physician residency yesLuiza F 1968 professor master yesMarcos M 1976 physician residency yesMilton M 1986 prof/phys master yesRenato M 1976 professor master noRoberto M 1986 professor master yesPedro M 1975 physician residency yes

Notes: Year grad is the year of graduation in medical school; Inst stat is the current institutionalaffiliation (whether a faculty professor or a university hospital physician – note that two ofthem have a double affiliation); Other degree is the highest academic degree held besides thatof MD, a means incomplete, and ‘livre docência’ is a title originated from the old privatdozentin Germany, usually accepted in Brazil as equivalent to a PhD degree, it is attained throughthe presentation and public exam of an original thesis and a written exam, without any formalcredits – in recent years it has been increasingly phased out in most Brazilian Universities;School egress refers to whether the interviewed subject graduated in that same medical schoolor not.




Table 2Themes, Definitions and Summaries

Theme Short description Summary from interviews

IUnder-graduateteaching

ideal models;assessment of currentsituation; assessment ofinterviewee’s rôle

There is a diffuse dissatisfaction among theinterviewees about some aspect or other ofteaching in medical school, especially in termsof a curriculum which is consideredinadequate. This seems to be a widespreadattitude in medical schools, judging by theexpressive production of critical evaluations ofmedical curricula [see, for instance, De Angelis(1999); Jason & Westberg (1982); Gastel &Rogers (1989)].

IIResearch

rôle of research inmedical education;interviewee’sparticipation inresearch; firsthandknowledge of ongoingresearch in theinstitution.

Personal participation in research activities isscarce and sparse, mostly related to preparingsome thesis for a postgraduate course, andconfined to that experience. The subjects didn’tmake any references to regular engagement inthe production of papers for publication, andin fact there are no records of expressiveproduction in that area for most of theacademic staff of the Clinical department ofthe medical school in the University’s datasystems. The interviewees also had practicallyno knowledge of any ongoing research at theUniversity hospital.

IIIPostgraduation

whether medicaleducators need otherpostgraduatequalifications.

Even for those who did have a graduate degreeother than the MD such credentials weren’tconsidered important for medical educators.For all the interviewees, it seems that there isbut one necessary and sufficient requisite forbeing a good professor in medicine: being agood doctor.

IVProfessors &physicians

differences betweenboth rôles in terms ofresponsibilities, tasksand attributed status.

Although in theory one could draw a preciseseparation between medical assistance andteaching, in practice these limits are completelyblurred. Clerical training dependsfundamentally on a hands-on approach, andparticularly in the university hospital it isimpossible to ascribe clear boundaries toseparate medical care and education.Nevertheless, some of those among theinterviewees who have the institutional status ofphysicians have a strong perception of theirposition as inferior to teachers.

VProfessionalvalues

interviewees’ views onsuch values.

All the interviewees highlighted the relevance ofhumanitarian values such as compassion,dedication, and so on and so forth. Not muchelaboration was done on this topic, it wasbrought about basically in response to thequestion on the characteristics of a gooddoctor.




Detailed Presentation of Text Excerpts Related to the Theme of ‘Knowledge’

I grouped the text excerpts in three subsections; they reflect recurrent sub-themes or trends in the interviews that usually coalesced after the inter-action had developed for a while. Once again, for reasons of space, I had tolimit actual quotations to a bare minimum.

First Sub-theme: A Doctor’s Job is Never Done – Knowledge is NeverComplete

This theme is commonplace in medical lore: there is a need to keep up-to-date about what is on the cutting edge of medical knowledge, which isassumed to be something that is growing all the time. At the same time, theother demands of the medical profession leave little room for this activity.This is immediately evident on the following quotes from the interviews:

I think that, for a clinician, keeping updated in medicine is very diffi-cult. . . . It’s impossible, especially now, with computers, the internet, with. . . an increasing diffusion of computers . . . to keep updated. . . . it’s verydifficult, with all your activities, and outside the profession, your family,your other activities, even your leisure, for you to arrange time forreading, then you do what you can, but it’s very difficult. [Luis]

I mean, I’m there on a daily basis from eight to five, and there are twodays that I go on straight until 8pm, at the outpatient unit. I have a weeklyshift here – 24 hours. When will I study? When will I take a course? I can’t,I have to do it myself, isn’t it so? On my own. [Marcos]

The other day . . . about a month ago I read a report . . . a quote in ajournal . . . that on the average two million new papers are publishedworldwide . . . that means journals all over the world . . . that’s per year,two million papers. In terms of major cardiology studies, there are threehundred great studies every year . . . there’s no human being, in principle,that has enough memory for all that stuff . . . per year . . . and has enoughtime to read it all. [Milton]

The same ideas are present in the next excerpts. First it is Alberto, oneof the elder members of the group, who expresses in these words the largeamount of reading that he is doing himself, and which, presumably, shouldbe an indication of how much needs to be done on a regular basis:

I don’t read medical journals, only. One day I read a journal, the other Iread a book. If you got . . . I’m reading the Stein [book], which is a huge

Table 2continued

Theme Short description Summary from interviews

VIKnowledge

strategies and sourcesfor acquisition; criticalassessment; relationshipwith practice.

This theme will be presented in detail in thefollowing pages, with quotes from the interviewtranscripts and a few comments on them.




book, this thick . . . I’m reading it and I’m going to read it from cover tocover . . . Then, I, being a clinician, am going to read this book from coverto cover, the same way I’ve read many others, from cover to cover.

The need for constant updating is expressed even more strongly in thisexcerpt:

. . . you force the student – and there is no other word, it’s really ‘force’ –to realize that he must be studying all the time, otherwise you’ll be . . .you’ll become outdated . . . the drugs . . . it’s really crazy . . . the number ofdrugs that they introduce to the market! [Celia]

Second Sub-theme: Looking for Needles in Multiple Haystacks –Selection Strategies

During the interviews, I asked the doctors how they select or triagerelevant/trustworthy/correct information from the multiplicity of sourcesthat constantly bombards them. The actual wording of the question variedaccording to the unravelling of the interview. This usually produced themost awkward situations: interviewees hesitated, grasped for words, ran incircles, and at times hardly made any sense at all. I often had to rephraseand reinstate the question several times before getting something from it,and even then, in some cases replies were not exactly informative. UsuallyI gave up pursuing the matter any further, for fear of inducing responsesout of excessive pressure. The most relevant aspect from the followingexcerpts is that there is no single pattern to them. I chose the term‘strategies’ rather than ‘criteria’ because, in all cases, no explicit criteriawere apparent, and they presented their behaviour in terms of examples,rather than as a methodical exposition of a set of rules. Actual strategiesvaried from subject to subject, and were usually fuzzy and difficult toexplain. Personal preferences, convenience, bits and pieces of information– such as those derived from developments in epidemiology – seemed all toplay variable parts in the composite strategies employed by theinterviewees.

Luis pointed to a mixture of personal interest, relevance for actualpractice, the relative authority of authors and journals, and a vague checkof ‘methods’:

. . . first you may try . . . an idea, you see? . . . see where this paper, thiswork came from . . . [it also should be considered] . . . the method theyused, the . . . the importance that it has . . . then at times, you have themeswithout . . . with very little interest to me. Such themes, or such subjects,I won’t . . . I won’t pore over. Now, if it’s something that might have someinterest to me, or might have . . . might help me, you’ll make at least asuperficial reading of that, to check what it’s about, and then if it’sinteresting you’ll read the whole paper . . . [Luis]

Alberto mentions the practical interest and the ‘cheats’ he uses asshortcuts:

I get a journal . . . [unintelligible] I look at the paper’s abstract. I look atthe abstract . . . if the guy . . . is talking about something specifically, if it’s




clinical stuff, I read everything. Now, what will I read? I won’t read . . . anabsurd, material and methods, as a general rule. I see it this way . . .[Alberto]

In another excerpt, Alberto makes his position as a mere consumer ofknowledge totally explicit, even if intertwined with medical practice – afterstating that research is important for generating new knowledge, he saysthat he does not have resources for doing it, concluding this way:

And I get the conclusions of research done outside. If I had to have this. . . I won’t try to conclude anything, I’ll get the conclusions that arealready available . . . [Alberto]

Jorge produced, after great insistence, a vague description of standards,without really elaborating them. He also refers to positions of authority,and his use of the verb ‘believe’ is particularly noteworthy:

Scientific knowledge is that which is validated, in my understanding bycriteria . . . accepted by the scientific community. Then . . . depending onthe criterion, also the basis of the work . . . I believe in allopathicmedicine, I had my schooling in this direction . . . I have to start with arandomized work, with criteria, controlled, published in a journal . . .[hesitates] with an editorial, a decent reviewing committee . . . I think thatthis is how it goes . . . a scientific work is one that follows normsuniversally accepted by science . . . [Jorge]

Celia also emphasizes personal experience and makes interesting remarksabout the role that reporting failures has in establishing credibility:

I also check . . . how many of these patients were unsuccessful. This is evena way for you to lend credit to that research, at least I think so. Because ifyou start out stating that your research was wonderful, was formidable,there’s something wrong with it. Could we be so bad at researching, thatwe have so many mistakes, so many . . . losses, you see? Then I try tocheck this. There’s always a lot of unsuccessful situations, and I think thatthis gives it more credibility – this is a bit weird . . . But I think it has morecredibility. [Celia]

Carla, the youngest interviewee, emphasizes the role of personal prefer-ences, but also of dislikes; she also mentions needs arising from practice:

I . . . first of all, there’s a lot of personal interest into it . . . that’s the firstthing . . . themes I like . . . It’s the two extremes, stuff I like a lot and stuffI totally dislike, but is the stuff that I force myself to study. Stuff that I likea lot, like . . . textbook, and read a paper, journal . . . the New England . . .and stuff I don’t like, then, I get the textbook, read, read, read until I canmake sense of it . . . review papers, that also help to understand . . . and soon. And the rest I fetch out of curiosity. Things that are fashionable also. Idon’t have a very large private practice, but . . . things that turn out at theoffice that we are forced to study, things that the patient . . . the patienthimself brings to us . . . [Carla]

Milton also talks about institutionally established sources of authority:




. . . [hesitating] We select . . . by the authors, the sources . . . who’spublishing it . . . the New England is the journal of the Harvard MedicalSchool. . . . [Milton]

Of all the interviewees, Roberto seemed the most disoriented by thisline of questioning, and referred vaguely to the role of common sense as ayardstick, but at the same time assuming it as an attribute or property ofindividuals, rather than a learned skill:

. . . [hesitates] . . . I see that issue from the point of view of common sensein medicine, and that’s what’s more important. That depends a lot on theperson who’s practising, I don’t know if that can be taught . . . [Roberto]

But Pedro is straightforward: it is important to have scientific – that is,proven – knowledge. He made no further elaboration on this point.

Scientifically proven is research stuff, isn’t it? There’s a lot of options. Yousee, to prove aspirin as anti-adhesive for platelets . . . it was proven. Therewere several other drugs which were not proven. There’s another slated forrelease next year. It’ll be released . . . that’s what I’m saying, anything cancome out of this . . . things change . . . [Pedro]

Luiza also stressed the importance of the journal that publishes the paperas a source of credibility, but introduced a cautionary note:

You’ll go after a paper, for instance, a paper from the Archives [of InternalMedicine], you already have a certain basis of those who already did thatkind of treatment, based on . . . and that’s why a clinician who is in thewards, seeing patients . . . working with the population, has to be updated,in fact. He is reading not to adopt the last paper, of the last person, butthat factor used worldwide . . . that routine, which conduct to be taken,that’s important. You don’t have to know the last thing . . . but the last butone, what’s being done all over the world . . . [Luiza]

Alexandre was the only interviewee to mention the existence of forces thathave to be resisted when it comes to acquiring updated medical knowledge,although even he did not manage to be particularly precise when it came toproposing alternatives:

The pressure, the media, and so on . . . if this is something important ornot . . . if someone says ‘this is the best available antibiotic . . . you have toprescribe this antibiotic, it cures everything, here’s the bacteriology’ . . . Ithink that the individual needs something like . . . the need for this criticalappreciation, you do not accept immediately . . . an evidence, even what isyour knowledge . . . some journals that try to filter some things, which arenot exempt from pressure . . . I think that clinical epidemiology is aweapon that you need to provide data for the patient, for the doctor sothat he can make certain decisions. [Alexandre]

Third Sub-theme: It Ain’t Necessarily So – Scepticism and Mistrust

In the previous subsection, a common trend of delegation can be seen inthe excerpts – instead of criteria of validity, there is an implicit accredita-tion placed on certain sources, mostly institutional, particularly certain




journals; the New England Journal of Medicine shines brightly as a consen-sual symbol of cognitive authority. From these it would seem that theinterviewees are content to play a passive role when acquiring knowledge.Not so. The following set of excerpts shows several reasons for not takingsuch information at face value, and reinstating once again the role ofpersonal experience in the process.

Roberto mentions the risk of relying on knowledge that is inherentlyunstable:

. . . we cannot base our conduct on a paper that just came out, becausenext week there might be another proving just the opposite, then we haveto be extremely cautious. There are some consensus panels that some[medical specialties’] societies do . . . consensus on the treatment ofhypertension, consensus for lipid disorders . . . which is the most dis-cussed on this issue in cardiology . . . and even these consensus resultscannot be applied, because it’s one thing trying to standardize conduct,especially in bulk . . . [pauses] . . . [Roberto]

Pedro refers to the same phenomenon, with even more emphasis:

. . . what happens is this: that’s what I’m talking about, there’s no use inreading too much, today’s truth is tomorrow’s lie . . . Isordil for heartfailure . . . when it was introduced, it was like that: every hour and a halfyou had to administer a sublingual capsule . . . Now you see that . . . withuse of the medication [unintelligible] . . . How many drugs you see thatare introduced, in the beginning as miracle drugs and then . . . disappear. . . a few years afterwards. You see that a lot, it’s not just a few cases, it’s alot. What’s the use of a book that comes out every two years . . . there’sa lot that was lost and was not for too long because it was not scientificallyproven that it is effective . . . [Pedro]

Alberto makes a penetrating critique of the effects of ‘publish or perish’policies in the overall quality of what is published:

. . . the guy does some work on gases. Darn! And in the end, what does theguy do? OK, gases. Alright, let’s study gases. But do you know whythe guy studies gases? To show off. He has to do some work. So, they say,like: ‘a good doctor is a doctor that publishes’. Then anything getspublished . . . any rubbish gets published. [Alberto]

And in this next excerpt, Alberto illustrates how medical perception can bebiased by theoretical conditioning, establishing very different roles andexpectations for the researcher and the clinician:

If [a doctor] only reads myocardiopathy, that’s all he’s going to see.Everything that turns out in front of him from that moment he’s trying tolearn about it on is myocardiopathy . . . Then I think that a doctor hasto read everything. . . . Unless he’s a researcher. When he’s a researcher ondisease and pericardial diseases, then he’ll only read pericardium . . .[Alberto]

These excerpts demonstrate that even when physicians recognize theepistemic authority of scientific sources – namely, research and published




papers – they recognize inherent characteristics that preclude an im-mediate transposition of what is published to actual medical practice,either because recent knowledge is also unstable knowledge, or becauserelevance criteria differ between the scientific arena and their daily prac-tice. A second thread of argument, not exactly like the preceding one, butclosely intertwined with it, is concerned with the rôle played by thepharmaceutical industry and its marketing strategies.

Celia strikes a similar note, raising additional reasons for taking resultsfrom papers with a grain of salt. She is speaking ironically about new drugsthat are released to the market:

They’re all wonderful, aren’t they?. . . Oh, it’s so good . . . perfect, marvel-lous, and all that . . . Then you’ll want your own experience, to knowwhether for your population, if that drug was good . . . how to achievethis? Of course there’s the literature, there’s someone who researched3000 patients using that drug . . . but sometimes it’s your patient who isthe one where it won’t work, but it’s a starting point . . . You won’t alwaysthink that . . . that it’s just advertising of the drug companies, and so on,but sometimes it does not work, Brazilian patients, you see . . . theseresearches are . . . USA, Europe, the biotype is different . . . the socio-economic status is different too . . . But I think that this is the way we do ithere . . . [Celia]

Marcos spells out the biases introduced by the pharmaceutical industryand the need of personally checking claims of effectiveness:

We get a patient in the ward, and we use that drug that has beenintroduced to the market for two, three months and we begin to apply it inthe ward. Then you see in loco the created situation, you’ll see if that’s justa fiction created by the pharmaceutical companies or if it’s reallyeffective.

Celia, once again, is even more explicit in describing the role of thepharmaceutical industry in shaping medical knowledge, in this passage:

You attend to a lecture where he says that the best drug to use against highcholesterol levels is X . . . then you look into it, he didn’t compare it withanything, you know, and in fact . . . Why did he say it was X? Because hewas funded by a drug company. That is . . . this is due to . . . this has to bewritten in the research reports, that you did it for the X, Y or Z drugcompany. The . . . I think it gets a bit biased when the drug companies arebehind it, but unfortunately in the majority . . . [Celia]

And the same point is made by Luiza:

And the pressure from the pharmaceutical industry is really something . . .They go to the hospital, to the ambulatory, drugs for hypertension . . . thepatient is there . . . you won’t administer a last generation inhibitor . . .betablocker, nothing like that, because that’s not our option . . . you knowthis . . . you’ll see a lot of patients, you’re consulting everyday . . . you’rereceiving the guy from the drug company marketing placing lots of freesamples there. [Luiza]




Discussion of the Findings

Considering the themes that were only briefly reported here (see Table 2),at least two of the statements made at the beginning of this paper arereinforced:

1. These doctors are not scientists, they are not involved in producingknowledge according to the institutional practices of science, and areconsumers of knowledge produced elsewhere. It might be argued thatthis derives from the fact that Brazil is a country with far less resourcesthan the most developed ones, but preliminary results from interviewsconducted with Canadian doctors indicate otherwise;

2. The lack of differentiation between the roles of physicians and pro-fessors in that institutional setting (the University Hospital), as well asthe lesser importance attributed to other academic degrees, is im-portant evidence of the placement of medical education as part of thebroader medical field.

A major issue is that of the perceived informational overload – what Iwould call the ‘Sisyphus Effect’. Doctors’ lack of spare time, at least in thisgroup, is an indisputable fact,9 as is the sheer volume of new publicationspoured continuously through an ever increasing number of journals. Butwhat might seem a next logical step, the commonsensical notion thatmedical knowledge is increasing at a dazzling pace, making everythingchange almost overnight, must be carefully considered.

This was evident in the quoted interview excerpts, but more examplescan be found almost everywhere without much effort. The clinical text-book quoted from earlier, Harrisson’s Principles of Internal Medicine [Issel-bacher et al. (1994)], has in its opening pages a disclaimer, encouragingreaders to confirm the information it presents with other sources. Thatnote begins with the following sentence: ‘Medicine is an ever-changingscience’. Even more explicitly, an Evidence-Based Medicine (EBM)manual justifies the need for EBM with the following reasoning:

First, new types of evidence are now being generated which, when weknow and understand them, create frequent, major changes in the waythat we care for our patients. Second, it is increasingly clear that, althoughwe need (and our patients would benefit from) this new evidence daily, weusually fail to get it. Third, and as a result of the foregoing, both our up-to-date knowledge and our clinical performance deteriorate with time.Fourth, trying to overcome this clinical entropy through traditional con-tinuing medical education programs doesn’t improve our clinical per-formance. . . . [Sackett et al. (1997): 5]

The idea of ‘progress of science’ and ‘medical advances’ could bechallenged on several grounds, but even if we take these for granted, how‘frequent’ and ‘major’ are the changes that they bring about? A study ofinnovation in medicine is far beyond the scope of this paper [an exampleof such studies, an extensive analysis of innovation in imaging techniques,can be found in Blume (1992)], but at least a few remarks are in order.




The bulk of innovation, both in terms of medical equipment anddrugs, comes currently from the private sector.10 This means that eco-nomic forces play a major role in such dynamics, and should be taken intoconsideration when analysing such changes in medicine. These marketshave a limited number of players, high-tech companies that are part oflarge transnational corporations. In such situations, competition usually isnot price-based. Considering the sheer volume of resources these corpora-tions have, a price war could rage for too long, and cause too manyeconomic casualties, possibly turning even the eventual winner’s finaltriumph into a Pyrrhic victory. In such situations, companies competethrough a strategy known as product differentiation. In order to boost sales,and instead of offering lower prices, companies rely on, often minute,technical differences in their products. This means, not only emphasizingminor differences between products from different companies, but alsopromoting successive versions in a line of products from the same com-pany. The temporal evolution of product lines in the auto industry and insome branches of consumer electronics, such as audiovisual equipment,provides concrete examples of such strategies. Going back to medicalindustries, there is a further element to be considered: patents. Copyrightsand protective legislation are effective shelters for securing revenues incertain market niches.

Analysing innovations in medicine from this angle, ‘frequent’, ‘major’changes seem less likely. Products have a life cycle, and introducing newproducts in the same categories in which old ones have not yet fullyrealized their profit potential becomes an unlikely scenario. A steady flux ofinnovations, which are either frequent or major, but rarely, if ever, both atonce, makes more economic sense. Reinforcing the idea that innovationsoccur at such a breathtaking pace, however, can be an extraordinarilyeffective marketing strategy. This is a point that will be fully addressed laterin this section, but, for now, what needs to be stressed is that this briefincursion into microeconomics gives at least some reason for taking claimsabout continuous revolutions in medical technology with a grain of salt.

With regard to notions of progress, we should also note the absolutedominance of English-speaking publications (both journals and textbooks)as the references for the interviewed doctors. This dominance is so over-whelming that many of the interviewees used an expression to refer totextbooks – ‘livro-texto’ – which is a literal but meaningless translation intoPortuguese of the English words ‘book’ and ‘text’.

The next element to be analysed is the selective strategy, or strategies,employed by the interviewed doctors. First of all, there is an interestingaspect in the way that they surfaced in the interviews. Considering that wewere discussing a routine operation in their daily lives, the fact that theinterviewees were at a loss to explain it is particularly intriguing. There isan interesting analogy here with the description of diagnostic strategiespresented by Sackett et al. (1991), especially with pattern recognition.According to these authors, a key component in medical diagnosis is theimmediate recognition of characteristic clusters of signs, which are grasped




as a whole, and not analytically one by one. The interesting thing to note isthat they say that, although an ex post facto reconstruction of a stepwiseprocedure may be described by the doctors, it does not describe whatactually happens in practice. The actual mechanism of pattern recognitiontakes place far too quickly for any deliberative procedure. This is in linewith Ginzburg’s conjectural paradigm [Ginzburg (1980)], which could alsobe described as a form of pattern recognition. It could thus be hypothe-sized that doctors employ similar strategies to sort out information whenseeking to update sources they use when diagnosing, quickly selectingcertain elements and reconstructing them in a gestalt. The difficulty theyexperience in explaining such procedures would may arise from the factthat they are not following a flowchart when executing their strategies, butoperating on a much more intuitive level.11 This observation also lendsweight to the hypothesis that ordinarily doctors are not fully competent toevaluate scientific journals. If this were the case, more definite, fullyconscious and systematic procedures could be expected.

The issue of competence demands some clarification. We can dis-tinguish at least two separate epistemic cultures, to refer once again toKnorr Cetina’s expression, within the field of biomedical research: labo-ratory experiments and epidemiological validation. The first is character-istically related to hard sciences such as molecular biology, and providesgeneral frameworks for explaining why certain drugs work the way they do,or how pathogenic agents produce the features of specific diseases. Theseexplanatory models are, to a large extent, irrelevant to actual medicalpractice, since a doctor does not need to know anything about quantummechanics, for example, to interpret the result of a MRI scan. Epidemio-logical validation, however, has a decisive influence in defining standardsfor medical practice. Marc Berg, for instance, shows how medical practicehas been reshaped over the last two decades by the introduction of severalstandardized protocols [Berg (1997)], and Ilana Löwy discusses the im-portance of randomized clinical trials for the introduction of new drugs ingeneral, and particularly in the treatment of desperate medical conditions[Lowy (2000)]. In both cases, it would seem reasonable to expect thatdoctors would understand the reasoning that leads to stating that drug A ispreferable to drug B, or that exam Y should be requested when conditionsX, W and Z are present. Unfortunately, such expectations are often notmet, in practice, and Evidence-Based Medicine, for instance, capitalizes onthis insufficiency.

It is also possible to derive a hierarchy of sources of knowledge fromthe interviews. At the highest level, as the most important source, liespersonal experience. Such experience includes bedside learning for medicalstudents. For doctors, it is more than hands-on, lived-through professionalexperience, because such learning is often acquired by proxy throughcontinuous interaction with colleagues and even students. On the secondlevel, there is textual information. There are three subcategories in this level:journal papers, textbooks and the internet. The internet is the mostdynamic and convenient source, although not necessarily the most reliable,




whilst books may be seen as inherently outdated, but also rock-solid whenit comes to proven knowledge. Papers occupy an intermediate position.These findings are strongly similar to Fleck’s description of varieties ofscientific communication quoted in the beginning of this paper, with twoimportant exceptions: the first is obviously the internet, which was notavailable in his time; the second and most intriguing is the lack of referenceto introductory handbooks. A possible explanation for this is that there areactually no clear-cut differences between textbooks (vademecums) andhandbooks (manuals) in clinical medicine.

Although there is consensus among the interviewees about the charac-teristics of each of these textual forms, the relative ranking of the im-portance of the different forms varies considerably depending on who wasinterviewed. Some of the younger doctors tended to rely more on theinternet than the older ones, but this was not always the rule. The mostenthusiastic user of the internet is Renato, who is in the mid-aged group.Alberto, one of the elders, although not as enthusiastic as Renato, is lesscritical about the internet than, for example, Luiza. Some recurrentexpressions also exhibit gradients, even within the same subcategory. Forexample, ‘footnotes’ in textbooks may be held superfluous, and the con-tents of ‘latest papers’ may be regarded as unstable and risky. Both areassociated with the ‘bookworm’ type of doctor, more concerned withtheory than practice, a stereotype with which none of the doctors wants tobe associated. Both the stereotype and its repulsiveness are strong evidenceof the epistemological primacy of experience for doctors. Doctors alsoemploy a clearly pragmatic, result-oriented approach, sometimes to such adegree that they dispense altogether with the need to know the metho-dologies employed in the studies. By the same token, the doctors inter-viewed do not assign much importance to information from the so-called‘basic sciences’. They do, however, rely on personal and/or institutionalmarkers of epistemic authority as selection criteria. Foreign books in theiroriginal language are more trusted than locally produced or translatedversions. As mentioned previously, the New England Journal of Medicine isunanimously acknowledged as a symbol of excellence. Curiously, Christa-kis et al. (2000) claim that no such bias was observed in a study theyconducted, even though the artificial situation created in their experimentwas completely different from actual practice. Christakis and his colleagueshanded papers from two journals to their subjects. Through no co-incidence, one of these journals was the NEJM. They disclosed the nameof the journal in some cases and not others, and subjects were asked to ratethem. After discussing limitations present in their research design, theysummarize their results with the following remarks:

These limitations prohibit us from concluding that journal attributionbias does not exist. Nevertheless, our results are encouraging. Theysuggest that given the opportunity and the dedication necessary to reviewan article or abstract carefully, physicians – regardless of their formaltraining in epidemiology or biostatistics – are able to read articles without




significant or large discernible bias based on publication source. [Christa-kis et al. (2000): 777]

The problem lies precisely in the fact that doctors lack the time to carefullyreview everything, and they select papers based on the reputation of theirsources before they read them.

Finally, at the lowest level of the hierarchy lie passive oral communica-tions: congresses, symposia, lectures, and meetings sponsored by the phar-maceutical industry on drugs being introduced (more on that later). Theseare ‘passive’ from the point of view of the interviewees, and should not beconfounded with learning by proxy, which is the result of systematicinterpersonal interaction that is tightly knit with professional practice.Although there is divergence in the appreciation of this kind of activity –Marcos, Celia and Luiza explicitly dismiss it, while Luis considers it alegitimate method of receiving ‘predigested’ information in an easy way –even those who still considered it useful place it at the bottom level.Training courses are occasionally mentioned, but usually as an impossi-bility due to the doctors’ busy lives. There is considerable overlap betweenthe levels of this hierarchy and the findings of Fernandez et al. (2000), whostudied similar sources of knowledge in medicine.

The last issue to be assessed in this section is the scepticism elicited inthe interviews. Medical scepticism is nothing new; in fact, therapeuticscepticism is used as a label to identify a period in medical history (the late19th century) during which most of the basic theoretical underpinnings ofmodern medicine were in place, although no modern therapeutic optionswere yet available. Doctors were then, as now, sceptical about theirpharmacopeia, yet had no other choice but to use them. Although present-day doctors may have more reason for trust than their 19th-centurycounterparts, they also lack alternatives that would fully empower them topursue their mistrust to its fullest extent. Going back to the economicargument previously presented, it should be noted that the production ofmedical knowledge, or more precisely, the production of knowledge withpossible medical uses, is also part of the same economic dynamics. Sincethe research is produced mainly by private sector companies with hugeeconomic interests at stake, there is a disproportionate concentration ofpower on one side of the trade. These companies produce the knowledge,funded through advertisements in the main journals. The journals also areedited by large publishing companies, which are, in a sense, part of thesame sector of the economy. (The same can be said about the mostrelevant textbooks.) Drug companies fund medical symposia and con-gresses and even subsidize individual doctors to attend such events. Thesponsors use such meetings to introduce new drugs, which have a curi-ously common mise-en-scene: a renowned specialist is invited to present thenew drug, usually in a luxurious setting like a top-ranking hotel; duringthe presentation, the invited authority never refers to the new drug by itscommercial brand, but only by its chemical name, although the venue isusually literally covered with signs and posters prominently depicting the




product’s and the drug company’s names. Finally, the most continuouslyoperated strategy involves the deployment of armies of marketing agentsfrom the pharmaceutical industry, who swarm around hospitals and clinicsand deliver free samples and gifts. Such practices have been demonstratedto affect prescription patterns of physicians [Wazana (2000); DiNubile(2000)]. There may be nothing inherently ‘wrong’ with these activities,but it is difficult to ignore the way medical knowledge is communicated inand through the marketing practices of the pharmaceutical, equipment andpublishing industries. There is a solid body of literature produced in LatinAmerica, especially Brazil, from the early 1970s to the present [un-fortunately, many of these sources, such as Cordeiro (1980), are nottranslated into English], focusing on the so-called medical-industrial com-plex. This expression, coined after Eisenhower’s famous remarks on thealliance between military, political and economical interests in the USA, isused to characterize the modern development of medicine in its relation toindustry. The analogy attempts to demonstrate that (a) medical ‘needs’ arenot spontaneous, but heavily induced by the supply of health care services,and that (b) economic interests tend to favour the deployment of suchservices so as to maximize profit, with no direct relation to actual needs ofpopulations, especially the poorer sectors. This should not be mistaken fora facile conspiracy theory: at issue is a configuration of mutually influentialinstitutional developments within capitalist societies. The medical pro-fession, its schools, teaching hospitals, the pharmaceutical industry, themedical equipment industry, technical publishing companies, all origi-nated in different places and times, but developed as intimately interrelatedinstitutions, forging a network of strong social, economic and epistemiclinks. Similar ideas are expressed by Blume, who interestingly also men-tions Eisenhower’s original expression [Blume (1992): 55].

Such an array of forces will inevitably introduce important biases intomedical knowledge and practice, as demonstrated by, among others, Stern& Simes (1997), who found evidence of publication bias favouring pub-lication of papers with positive evaluations of treatments; Friedberg et al.(1999), who describe a similar situation with regard to cost-effectivenessstudies, in a paper that prompted an editorial comment urging more strictguidelines for the submission of cost-effectiveness studies for publication[Krimsky (1999)]; and Stelfox et al. (1998), who demonstrated a correla-tion between links to the pharmaceutical industry and sides taken on thedebate about a specific drug. While DiNubile (2000) deplores this situationas a result of doctors being insufficiently sceptical, this does not seem to bethe case, necessarily. The sceptical stance of the interviewees in my studywas clearly evident and well argued. Almost all interviewees providedexamples – compelling anecdotal evidence – of cases in which guidelineswere not strictly followed and therapeutic success was achieved, anyway,and they also described the converse situations in which strict adherence toguidelines did not result in success. However, doctors lack resourcesto fully pitch their scepticism against the massive forces of the medicalknowledge industry. This is not much different from the situation of the




hypothetical dissenter described by Latour [(1987): 21–100], who keepschallenging scientists’ claims, only to be finally silenced by the dazzlingarray of resources that the latter can enrol in their support. No matter howsceptical, in the end the doctor has no choice but to give in.

There are two possible objections that need to be addressed at thispoint. First, it could be argued the interview responses do not describe thedoctors’ actual practices. Second, since the interviews address only generalpractitioners, it could be argued that they do not necessarily represent theviews of specialists, particularly those in the more high-tech areas ofmedicine.

With regard to the first objection, it should be noted that the inter-viewing strategy was designed so that respondents would not know theactual goals of the research. The idea was to minimize the ‘right answers’effect. Second, we can take into account the results from a second leg ofthe study (the detailed results are not presented in this paper). Puttingtogether both legs of the study, a total of 24 interviewees from 2 differentinstitutions, facing 2 different interviewers, provided consistent responses.Finally, even if interviewees were, in the worst possible case, grosslymisconstruing their opinions, beliefs and deeds in the interviews, thatmisrepresentation would still be based upon presumably correct approa-ches, indicating the shared values that are actually more important to thisstudy.

With regard to the second objection, I would emphasize once again therole of the interviewees in forming opinions, given their pre-eminence bothas doctors and professors, particularly in the second role. They contributeheavily to shaping of the views of future doctors, general clinicians andspecialists alike. It should also be noted that, although the interviewees areall professors of internal medicine, this does not mean that they havenot specialized in other fields. As a matter of fact, most of them are alsospecialists, even in high-tech areas.

The exploratory nature of this study was mentioned at the beginningof this paper. Additional research is necessary before the conclusions thatfollow can be widely extrapolated. As noted, another set of interviews, stillbeing analysed, was conducted with Canadian professors, and an ethno-graphic phase of the study is still under way. Another research project,related to the one reported here and dealing with similar issues in cardiol-ogy, is still being carried out. In any event, this is, as it has been previouslystated in this text, an area that demands more attention than it has receivedso far.

Conclusions: Consequences of a Particular Thought Style

To put this study in perspective, it is important to go back to Fleck’sgeneral framework in order to assess how well his categories apply to whatis being described here. I believe that at least his two basic constructs arestrongly relevant: the doctors in this study are part of a community thatmaintains systematic intellectual interaction, thus qualifying as a ‘thought




collective’; and the interviews at least hint at the existence of certainconstraints on thought that make doctors see things in specific ways whileexcluding others. For instance, despite having qualms about specific drugs,particularly newly introduced drugs, there is no question that drugs are amajor (if not the major) tool for dealing with health problems. The strongtendency to prescribe drugs would thus characterize a ‘thought style’.With regard to the distinction between practitioners’ and researchers’thought styles, the fact that the interviewees consistently rely on sources ofauthority which are outside the reach of their own experience adds strengthto the idea that they are included in the ‘exoteric’ circle, if not the core‘esoteric’ group of researchers who are recognized experts in the researcharea.

The thought style that emerges from this set of interviews can bebriefly characterized as a largely intuitive,12 pragmatic, result-orientedsearch of relevant (that is, potentially useful in practice) information,selected from sources with sufficient academic credibility. Further, thethought style emphasizes the primacy of practical, experiential knowledge,and expresses a sceptical stance, at times bordering on cynicism, towardthe latest innovations. Despite this scepticism, however, doctors lackresources (namely, time, knowledge of technical aspects of research, par-ticularly in terms of epidemiology and statistics) to effectively assessknowledge that is constantly being force-fed to them. This relative lack ofresources is worsened on one side by the perception of medicine as subjectto frequent and major changes – another example of the type of perceptualcoercion produced by a thought style – and, on the other, by the vastlydisproportionate forces available to those who effectively produce anddistribute such knowledge.

The net effect of this situation is the receptivity of the medicalprofession to the pre-digested and pre-selected information presented bythe industrial side of the medical-industrial complex. Sheldon Ramptonand John Stauber’s book on the strategies of corporations to enrol scien-tists’ support to their PR interests quotes a number of clearly documentedcases in which several companies, from tobacco to pharmaceutical in-dustries, were able to hire scientists to produce (or, in the worst cases,simply sign) papers reflecting their interests that were published in presti-gious journals, even the NEJM [Rampton & Stauber (2000): 200–04]. Thesame book documents how sources of funding bias research protocols and,consequently, their outcomes [ibid.: 217–21]. Doctors’ pursuit of up-to-the-minute knowledge, one of the features of their thought style, isacknowledged and used by the medical knowledge-industry to its ad-vantage. Currently proposed remedies, such as the adoption of strategiesbased on the so-called ‘Evidence-Based Medicine’ have among othershortcomings the failure to acknowledge the extensive social, economicand even political roots of the dilemmas faced by doctors. Additionally,their reliance on a cookbook approach to statistics undermines doctors’trust in their own specific forms of knowledge, derived from a clinicalmethod which emphasizes individual cases, and further reinforces their




epistemic dominance by a discipline that they usually do not fully grasp. AsIsaac Asimov wrote in his 1991 science fiction novel, Prelude to Foundation,‘Not all persons would be equally believed . . . A mathematician, however,who could back his prophecy with mathematical formulas and terminol-ogy, might be understood by no one and yet believed by everyone’ [Asimov(1991): 5].

The healthy scepticism of the doctors needs resources to match theforces it opposes. The production and diffusion of medical knowledge arethus also public health concerns, and as such should be addressed bypublic policy, and, especially, more strongly funded by the public sector.Going back to the question formulated at the beginning of this paper, theway doctors evaluate knowledge is mostly intuitive and dependent uponauthoritative sources. Consequently, doctors would certainly benefit fromadditional resources that can help them to perform this task.

NotesThis work was made possible by grants from Brazil’s National Research Council (CNPq),the Brazilian Education Ministry’s Committee for the Development of Human Resources(CAPES), and Rio de Janeiro State University (UERJ). The author wishes to express hisdeepest thanks to McGill University, its Department of Social Studies of Medicine, and, inparticular, to Professors Allan Young and Don Bates, without whose help this paper wouldnot exist. This paper is dedicated to the memory of Professor Don Bates.

1. For a detailed account, see Fleck (1979) and also Cohen & Schnelle (1986), a bookthat presents some of Fleck’s previous papers and critical assessment and commentaryby a variety of authors. On Fleck’s relevance to contemporary studies in science andmedicine, see, for instance, Hacking (1999): 60, and Kuhn (1979), (1996): viii–ix.

2. Fleck refers to Durkheim in his book [Fleck (1979): 46], albeit criticizing him,alongside others, for their ‘. . . excessive respect, bordering on pious reverence, forscientific facts’ [ibid.: 47].

3. Although for reasons of space this issue will not be dealt with in this paper, MichelFoucault’s archaeology of knowledge is also relevant to the discussion: see Foucault(1972), for his own critical reappraisal of his previous writings. A comprehensiveaccount of Foucault’s work up to and including the ‘Archaeology’ can be found inGutting (1989).

4. Even though I stand by these remarks, the current stage of this research involves thedirect observation of the interactions between a professor and final-year medicalstudents and residents. This ethnographic research is useful for the purpose ofestablishing triangulation between the results produced by different techniques.

5. The actual name of the University is not given, for reasons of confidentiality.6. For a second step in this research, this procedure was repeated on a second school, also

ranked among the best and most influential in Brazilian medicine, where 10 moreinterviews were conducted by a research assistant under my supervision. Although thesecond set of interviews is complete, it will not be presented in this paper, except for abrief discussion in the conclusion. Another set of interviews was conducted in Canada,but its analysis is not yet finished.

7. I presume that the knowledge that the interviewees had of my own previousinstitutional affiliation, that of a staff member in the medical psychology unit in theUniversity Hospital, may have had an important influence on their responses, sincethey might be attempting to address – even if they were not fully aware of it –what they believed were my concerns and beliefs. For example, almost all of theinterviews stressed the importance of humanitarian values for the profession. They werenever specific about exactly what that meant, how they would be translated into




practice, whereas with regard to other aspects of medical practice they provided ampleclarification, examples, case anecdotes, and so forth. Obviously, there are technicalaspects to dealing with human emotions and subjectivity, but this does not seem to beacknowledged by the interviewees (perhaps I should say by the medical profession as awhole), who trust vague common sense to deal with such matters. There is a contrastbetween how much theoretical knowledge the interviewees seemed to consider asrequired when prescribing a drug, for instance, versus counselling and similar ‘soft’approaches to care, so the statement that such items were important for the medicalprofession was contradictory.

8. Another point worth mentioning is the use of male pronouns throughout theinterviews. Although Portuguese is a gendered language, in the sense that possessivenouns, substantives and some adjectives have suffixes indicating gender, in situationswhere gender is not known or not important (for instance, when giving an exampleabout a generic doctor’s actions) usage of the equivalent pronouns to ‘he’ and ‘him’, aswell as the male version of certain substantives such as the Portuguese versions of‘doctor’, ‘man’, ‘guy’, and so on, remains the grammatical norm, and thus these wordswere retained in the translation. It should be noted that this observation is not in anyway specific to the interviewees, applying generally to the way that Portuguese is spokenand written, at least in Brazil.

9. It should also be noted that all interviewees had at least one other job besides theUniversity position, also a common situation in Brazil; this is linked to the patterns ofthe medical job market in this country, and will not be explored here.

10. Interestingly, the proceedings of a conference sponsored by the New York Academy ofSciences on the evaluation of health care interventions [Warren & Mosteller (1993)], inwhich major proponents of EBM were keynote speakers, managed to steer clear of thisrather obvious fact.

11. An alternate explanation to their hesitation when asked how they actually keep up withthe development of medical knowledge was proposed by one of the reviewers of thefirst draft of this paper, who suggested that this could be a potentially vexing situation,since they could seem lazy or incompetent if they acknowledged how little they actuallymanage to read. Although I cannot rule out this explanation, I do not think that thiswas the case, mainly because the question was not posed in such a way as to point tohow much one should read, but how reading should be prioritized.

12. The importance of intuition in medical practice is stressed both by Fleck (1986) andGinzburg (1980).

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Kenneth Rochel de Camargo, Jr is a researcher and associate professor atthe Instituto de Medicina Social of the Universidade do Rio de Janeiro,




Brazil. His current research deals with the process of production, diffusionand utilization of medical knowledge.

Address: Instituto de Medicina Social, Universidade do Estado do Rio deJaneiro, R.S. Fco. Xavier, 524, 7o Andar Bloco D, Rio de Janeiro, RJ,20559–900, Brazil; fax: +55 21 2264 1142 or +55 21 2569 3077;email: [email protected] or [email protected]




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