Ludwik Toresminho

ABSTRACT The differential selection and assessment of knowledge is a key feature of
medical practice. This paper presents a study of how doctors select and assess
information in practice. Fourteen internal medicine professors from a relevant
medical school in Rio de Janeiro, Brazil, were selected through preliminary interviews
with medical students. The professors were subjected to open-ended interviews. The
resulting material was interpreted through a conceptual framework derived from
Ludwik Fleck, in order to establish the relevant elements of the thought style
characteristic of the way they select and acquire new knowledge. The thought style
that emerged from this set of interviews can be briefly characterized as a largely
intuitive, pragmatic, result-oriented search of relevant (that is, potentially useful in
practice) information. The doctors sought sources with academic credibility, but they
maintained primary interest in practical, experiential knowledge. They also expressed
a 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 knowledge
that 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 who
effectively produce and distribute such knowledge.
Keywords
epistemology, medical anthropology, medical knowledge, thought style
The Thought Style of Physicians:

Strategies for Keeping Up with Medical
Knowledge
Kenneth Rochel de Camargo, Jr
Cognition is therefore not an individual process of any theoretical particular consciousness. Rather it is the result of a social activity, since the
existing stock of knowledge exceeds the range available to any one
individual. [Ludwik Fleck (1979): 38]
Although it would be far too simplistic to assume that knowledge is the sole
or even the ultimate determinant of actual medical practice, the existing
stock of knowledge (as in Flecks epigraph) surely plays a major role
in this
regard. Much of what a physician does can be described in terms of
making decisions based on trusted knowledge that (s)he is constantly
updating. This means selecting specific items from a plurality of sources,
and also differentially evaluating their relevance and intrinsic merits. It
thus follows that assessing the validity of certain statements concerning
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Social Studies of Science 32/56
medical knowledge is an integral part of medical practice; this is clearly an

epistemological enterprise.
Before proceeding, a cautionary remark has to be made. Giving a
precise definition of what knowledge means depends on the underlying
philosophical framework of choice. The Cambridge Dictionary of Philosophy,
for instance, ties such definition to a discussion about epistemology [Audi
(1999): 27375], whereas Ian Hacking includes it in his list of elevator
words that is, words that are made to work at a higher level than those
used to describe facts and ideas, and which are usually circularly defined
[Hacking (1999): 2223], and Fleck, finally, simply uses it without bothering to define the meaning. In order to avoid the potential pitfalls of such a
complex discussion, knowledge in this text is equated to the cognitive
content acquired from formal education, professional practice or technoscientific literature.
This paper is a report of a qualitative, exploratory study whose
objective is to answer the following questions: what are the strategies that
doctors 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 to
do it?
This is a key issue with repercussions in several areas of research and
public policy, such as the quality and costs of medical care; the incorporation of new technologies in current practice; and the emergence and
diffusion of innovation in medicine. Regardless of its importance, however,
this is an aspect that remains relatively under-researched. Most of the work
has been done by epidemiologists, particularly those gathered under the
self-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 concerned
with slightly different aspects than the investigation reported here; in
particular, the specifically epistemological aspects of medical reasoning,
which is a key issue for this work, are usually left aside.
Conceptual Framework
Ludwik Flecks comparative epistemology [Fleck (1979)] offers a unique
set of tools to look at the production and circulation of knowledge in
contemporary societies, especially when related to the biological sciences
and medicine. The following lines will present briefly some highlights of his
theoretical developments.1
Two concepts stand at the core of Flecks comparative epistemology:
the thought collective (Denkkollektiv) and thought style (Denkstil). He
described the first as . . .
. . . a community of persons mutually exchanging ideas or maintaining
intellectual interaction, we will find by implication that it also provides the
Rochel de Camargo: Thought Style of Physicians
829
special carrier for the historical development of any field of thought, as

well 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 of
intellectual preparedness or readiness for one particular way of seeing and
acting and no other. [Fleck (1979): 64]
It must be stressed that the thought style is not an optional feature that can
be wilfully, consciously chosen, but rather an imposition made by the
process of socialization represented by the inclusion into a thought collective.2 It should also be noted that although style, like Kuhns
paradigm has the kind of semantic fuzziness that allows for all sorts of
abuses, it is nevertheless Flecks word of choice, and I am using it in the
sense of his precise definition.
Fleck distinguishes two major areas within a thought collective in
modern science [Fleck (1979): 11112], one comprising the experts that
actually produce knowledge, which he calls the esoteric circle (he further
details this region, describing the inner circle of the specialized experts and
the outer of general experts), and the other consisting of the educated
amateurs, the exoteric circle. This epistemological topography allows the
distinction between different forms of communication [ibid.: 112]: expert
science is characterized by journal and vademecum (or handbook) science,
the first representing the intense, fragmentary, personal and critical dialogue within a given field of knowledge, and the second a synoptic
organization of the former [ibid.: 118]; the exoteric circle is fed through
popular science, which is . . . artistically attractive, lively, and readable
exposition with last, but not least, the apodictic valuation simply to accept
or reject a certain point of view [ibid.: 112]. Finally, introduction to the
esoteric circle which Fleck compares to a rite of initiation [ibid.: 54] is
based on yet a fourth type of scientific text medium, the textbook [ibid.:
112].
These elements allow for the construction of a geography of an
intellectual field, describing not only peoples and places, but also the
interchanges taking place between them. I do not intend, however, to
ascribe more value to such objects than that of a convenient notation
turning Flecks model into an ontologically founded account would, in a
sense, be going very much against the very gist of his ideas.
All medical institutions (including public health, health care and
medical schools), as well as medical knowledge and practice, are permeated by a specific thought style. This does not mean that medicine is a
homogenous epistemological region. Science itself can hardly be described
in general terms, being divided into different kinds of scientific practice,
which configure different cultures, according to Knorr Cetina (1999). This
is further complicated in medicine since its mainstay is not the production
of knowledge, but its application in a variety of situations according to
830
ethical principles [Canguilhem (1978): 134]; even though a description of

a medical style of thinking can be sketched [see, for instance, Fleck (1986);
Bates (2000); Luz & de Camargo (1997)], it should not obfuscate the
extreme differences within that field. This might pose an obstacle for
utilizing Flecks framework in effect, any epistemological framework to
analyse the knowledge of practitioners, rather than researchers. It should
be noted, however, that there is nothing in Flecks definitions of a thought
style and a thought collective that specifically ties them to communities of
researchers in fact, he refers to the world of fashion in order to exemplify
the general structure of a thought collective [Fleck (1979): 10708].
Additionally, in a pre-Genesis paper [Fleck (1986)], he describes what he
views as specific features of the medical way of thinking, an expression
that can be seen as a step along the road of the development of the concept
of a thought style. That text dwells quite extensively on the differences
between the medical and the scientific ways of thinking. Taking such
differences into account, as well as the idea that in complex societies there
are multiple intersections and interrelations among thought collectives
[Fleck (1979): 107], one can conceive of at least two distinct thought styles
in biomedicine: researchers and practitioners. There is, however, a wide
area of overlap between them.
Anthony Giddens [(1990): 27] described how lay people rely on what
he calls expert systems in everyday life, meaning the myriad of technologies
that we interact with on a daily basis without really having a firm grasp on
how 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 industrial
society, this means that everyone is a lay person in many areas [see also
Knorr Cetina (1999): 67]. Expert systems also exist in medicine, and at
least some of them are as unreachable to regular doctors as to lay persons,
although the former may be exposed to those systems through their
authoritative, textbook science variety, version. This does not mean that
doctors access to journals and all sorts of papers during their careers will
be blocked, but it does mean that they might lack the necessary skills to
effectively interpret what is omitted and compressed in these papers. In a
commentary that parallels Flecks remarks on the same subject, Allan
Young illustrates this point by drawing an analogy between scientific
literature and Conan Doyles stories of Sherlock Holmes:
. . . there is a growing literature dedicated to the rhetoric of scientific
writing. A favourite argument of these authors is that, when scientists
write journal articles, they erase the boundary between real time (contingent, undetermined) and narrative time (logical, causal). The erasure is
achieved through rhetorical conventions, such as the use of passive voice
(results were obtained) and the absence of any reference to human
agency (no personal pronouns). My impression is that, despite these
devices, competent readers of scientific journals can tacitly recognize the
co-existence of the two kinds of time real/contingent and narrative/
determined in the work they read. On the other hand, in popular science
magazines, erasure is attempted through other means: original reports are
aggregated, renarrated and oriented to a shared telos (a notable scientific
831
discovery). Non-scientist readers of these magazines are analogous to

the readers of Watsons accounts, in that they seem inclined to mistake
narrative time for real time. [Young (1995): 357]
Extrapolating from Youngs distinction, my contention is that physicians

are competent readers of scientific journals, only to a limited extent.
Since they lack adequate contextual information, they are unlikely to be
able to unravel the two kinds of narrative in scientific papers, and are more
likely to take statements at face value.
Modern medical knowledge and practice draw from a variety of
theoretical/technical sources, from quantum mechanics (the basis of the
most advanced imaging methods) to molecular biology, filtering them
through several techniques of assessment and validation, which are part of
another discipline, epidemiology, which in turn relies heavily on mathematical more specifically, statistical tools in its trade. None of these
areas of knowledge is the intellectual province of the practising physician;
in Flecks terms, the latter are at most part of the exoteric circle of the
thought styles of those areas. This brings back the question posed at
the beginning of this paper.
The process of schooling that turns the medical student into a fullyfledged medical doctor is an organized inculcation not only of certain
cognitive contents but also of a distinctive way of defining what reality
itself is [Atkinson (1997); Good (1994): 6587]. This learning is integrated
into a system of opinions that, once again according to Fleck, resist
challenges tenaciously, creating what he described as the harmony of
illusions [Fleck (1979): 2738]. An essential part of that thought style is a
set of criteria that identifies trustworthy knowledge, usually identified as
true, objective and scientific, according to what Good dubbed biomedicines folk epistemology [Good (1994): 810]. Indeed, claims to the
firm rooting of biomedicine in scientific knowledge are widespread, as can
be witnessed in the introductory chapters of clinical handbooks [see, for
instance, Barker et al. (1999); Isselbacher et al. (1994); Kassirer &
Kopelman (1991)], or in popular science books expressly dedicated to
dispel any ideas that medicine might not be grounded in science [for
example, Weatherall (1995)]. The abusive use of the word scientific and
the counterpart expression not scientific, however, has been noted at least
by one author [Brewin (2000): 586], who wrote: Why not choose plainer
words like abundant or scanty, convincing or unconvincing, objective or
subjective?
Assessing criteria for the selection of trusted knowledge poses a
problem in terms of Flecks original work. Whereas he used scientific texts
as the basis for his analysis, in order to understand how doctors evaluate
knowledge the starting point cannot be the texts themselves, since the
thought style determines which texts are read, how they are read, and how
(or if) they are incorporated into the available stock of knowledge. A
different approach is thus required. Given Flecks description of a thought
style as a definite constraint on thought, its characteristics should also be
832
present in other forms of discursive production,3 as speech itself. In this

regard, the meaning of certain words currently used in appraising the
knowledge 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 Wittgenstein [(1997): 39, paragraph 83], to play the language game where such
meanings make (or gain) sense. In other words, it is necessary to interact
and talk to people who are part of that thought collective. How to talk, and
to which people, are issues that will be dealt with in the description of the
methodology of this study; what remains to be seen in this section is how to
reconstruct such meanings once the pertinent data is gathered.
Methods
In order to gain access to the language games of my subjects, I decided to
use interviews as my main methodological instrument [for an in-depth
review of the methodological and theoretical issues related to interviewing
techniques, see Fontana & Frey (2000)]. It should be noted that the use
of 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 for
analysis the culturally rich methods through which interviewers and interviewees, in concert, generate plausible accounts of the world [ibid.: 823].
Even then, it could be argued that perhaps a classic ethnographic study
would be a better approach.
I have three reasons for my methodological choice. First of all, I would
say that I sacrificed depth for breadth; given the available time for fieldwork, I would be able to study at most one ward in the hospital, and thus I
would have had access to one, at most two, of my interviewees in the
process, whereas I considered a multiplicity of interviewees to be important for the study the advantages of having multiple voices in a
comparable study were stressed by Gilbert & Mulkay [(1984): 188].
Second, it must be noted that, having graduated in medicine, I am part of
the same esoteric circle, and thus at least minimally competent in that
language. Although firsthand experience cannot be equated to a rigorous
ethnographic procedure, it certainly allows for an intimate knowledge of
the field. My previous personal and professional experience served both as
context for filling gaps and, at least to some extent, a measure of comparison. Finally, as the results will show, much of the actual process of
selecting and incorporating new knowledge takes place in spaces other
than the workplace, and a traditional single-site ethnographic observation
would leave these out.4
I interviewed medical school professors, because they are in charge of
the reproduction of values in the profession. Additionally, those professors
are also usually respected doctors too, thus occupying a pre-eminent
position in the medical field. This meant that, in terms of language games,
833
at least three different kinds of interaction could be postulated beforehand

in the context of this study: among clinicians; between these and medical
students; and finally between the clinicians and the interviewer myself.
Based on my experience, I consider the first two of these interactions as so
intertwined in the clinical setting as to be part of an inextricable continuum, 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 an
assumption; 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 in
Rio de Janeiro for the field research,5 which is also the medical school
where I graduated. This choice was based on the assumption that such
familiarity would make the initial steps in the field easier, an assumption
that proved to be correct with the unfolding of the research, although it
brought about other difficulties, which will be dealt with later in this
paper.
The next step was to choose which professors should be interviewed.
First of all, I decided to choose internal medicine professors as interview
subjects, rather than more specialized professors, since all students are
exposed to internal medicine for long periods of time during their training
in medical school. Medical specialists tend to teach short-term courses,
thus having less exposure to the students and being less influential, on
average, in the process of building the future doctors worldview.
In order to narrow the set of interviews further, the most respected
professors were identified. An assistant researcher, a medical student who
joined my research project, conducted a series of interviews with medical
students in the last three years of medical school (these students had
contact with most, if not all, the internal medicine professors). My
assistant asked the students to identify the best professors, in their opinion.
These interviews yielded a list of 18 names, among which were some
University hospital staff members who, although not professors in the
strict 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 4
of the 18 professors during the time frame of the study, for different
reasons (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 University
hospital, when the schedule for the interviews was arranged. Formal
introductions were unnecessary at this hospital, since I had previous
acquaintance with all the subjects. All interviews took place in a relatively
quiet room near the wards in which the subjects usually worked, during
free slots of their usually busy schedules. All interviews were taped, with
consent from the interviewee, and ranged in time from 35 minutes to an
hour and 40 minutes (approximately). Both the initial contact and the
opening of the interviews were standardized: I informed the subjects that I
was conducting a study on medical teaching, and during the interviews
834
I asked three standard questions: what was the doctors academic background; what, in her/his view, were the most important features in a
doctor; and what would an ideal medical school be like. These questions
had no relevance in themselves, as they were designed to help set up a
shared orientation to the questions that followed. As the interviews proceeded, I would ask, for example, how they updated their knowledge, and
how they sifted relevant information from the overwhelming jumble that
medical journals and, more recently, the internet, presented. If research
activities were not spontaneously mentioned, I would ask about their
personal involvement with research, and/or the relevance that it would have
in medical education.
Interviews always present the risk of inducing subjects to respond with
what they would deem appropriate answers, even if these did not actually
represent their views. I chose this extremely indirect approach in order to
minimize that risk.7
The resulting interviews were transcribed, and the text files were
stored using a free software package called Logos, a textual database system
developed in Brazil specifically as an aid to the analysis of unstructured
data [de Camargo (2000)]. Each interview generated a record in the file,
which was analysed for the presence of recurring themes connected to
medical knowledge, practice and their relationship. Text chunks were
coded according to the presence of these themes, and then regrouped
according to them. The choice to work with themes rather than specific
words is due to the fact that several different words can be semantically
related, even if they are not exact synonyms, and because the goal of the
research is to reconstruct a thought style, not a lexicon. The themes and
the 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 a
spoken interaction while translating from Portuguese to English. What may
look at times like broken English is the result of a deliberate effort to
preserve the spontaneity and even the awkwardness of the spoken language, 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 replaced
with pseudonyms in order to preserve interviewees privacy.
A few characteristics of the group should be noted. First, there are
many fewer women than men in the group, probably reflecting the composition of the faculty of the medical school. It is also of interest that the
distribution of time since graduation is heterogeneous, with aggregation in
some periods; this reflects changing recruitment policies in the University
over the years. The majority of the interviewees graduated from the same
school, which is not an unusual situation in Brazil. None of them has a
835
doctoral degree other than the MD (although one of them has a qualification which is considered equivalent in Brazil to a PhD), and four of them
had not even a masters degree. This is also not unusual in medical schools
in Brazil, especially in the clinical courses, although this situation has been
changing in recent years; it should be noted that this group is better
qualified in this sense, anyway, than the bulk of the professors of the same
department (or comparable hospital doctors), and this may have had an
impact 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 be
more likely to receive better evaluations from their students. In any event, it
is 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 itself
an integral part of the analysis [Ryan & Bernard (2000)] yielded six
recurring themes in the interviews. For reasons of space, only one of the
themes the second most frequent in the interviews, and undoubtedly the
most relevant for the core issue of this paper will be extensively presented
and analysed here; the other five will only be briefly commented upon. The
themes are presented in Table 2.
TABLE 1
Characteristics of the Respondents
Pseudonym
Sex
Year grad
Inst stat
Other degree
School egress
Alberto
Alexandre
Carla
Celia
Celso
Jorge
Lauro
Luis
Luiza
Marcos
Milton
Renato
Roberto
Pedro
M
M
F
F
M
M
M
M
F
M
M
M
M
M
1965
1974
1992
1984
1968
1983
1959
1984
1968
1976
1986
1976
1986
1975
professor
physician
professor
physician
professor
prof/phys
professor
physician
professor
physician
prof/phys
professor
professor
physician
livre docncia
master
residency
mastera
master
mastera
none
residency
master
residency
master
master
master
residency
no
yes
yes
no
yes
no
yes
yes
yes
yes
yes
no
yes
yes
Notes: Year grad is the year of graduation in medical school; Inst stat is the current institutional
affiliation (whether a faculty professor or a university hospital physician note that two of
them have a double affiliation); Other degree is the highest academic degree held besides that
of MD, a means incomplete, and livre docncia is a title originated from the old privatdozent
in Germany, usually accepted in Brazil as equivalent to a PhD degree, it is attained through
the presentation and public exam of an original thesis and a written exam, without any formal
credits 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 school
or not.
836
Table 2
Themes, Definitions and Summaries
Theme
Short description
Summary from interviews
I
Undergraduate
teaching
ideal models;
assessment of current
situation; assessment of
interviewees rle
There is a diffuse dissatisfaction among the

interviewees about some aspect or other of
teaching in medical school, especially in terms
of a curriculum which is considered
inadequate. This seems to be a widespread
attitude in medical schools, judging by the
expressive production of critical evaluations of
medical curricula [see, for instance, De Angelis
(1999); Jason & Westberg (1982); Gastel &
Rogers (1989)].
II
Research
rle of research in
medical education;
interviewees
participation in
research; firsthand
knowledge of ongoing
research in the
institution.
Personal participation in research activities is

scarce and sparse, mostly related to preparing
some thesis for a postgraduate course, and
confined to that experience. The subjects didnt
make any references to regular engagement in
the production of papers for publication, and
in fact there are no records of expressive
production in that area for most of the
academic staff of the Clinical department of
the medical school in the Universitys data
systems. The interviewees also had practically
no knowledge of any ongoing research at the
University hospital.
III
Post
graduation
whether medical
educators need other
postgraduate
qualifications.
Even for those who did have a graduate degree

other than the MD such credentials werent
considered important for medical educators.
For all the interviewees, it seems that there is
but one necessary and sufficient requisite for
being a good professor in medicine: being a
good doctor.
IV
Professors &
physicians
differences between
both rles in terms of
responsibilities, tasks
and attributed status.
Although in theory one could draw a precise

separation between medical assistance and
teaching, in practice these limits are completely
blurred. Clerical training depends
fundamentally on a hands-on approach, and
particularly in the university hospital it is
impossible to ascribe clear boundaries to
separate medical care and education.
Nevertheless, some of those among the
interviewees who have the institutional status of
physicians have a strong perception of their
position as inferior to teachers.
V
Professional
values
interviewees views on
such values.
All the interviewees highlighted the relevance of

humanitarian values such as compassion,
dedication, and so on and so forth. Not much
elaboration was done on this topic, it was
brought about basically in response to the
question on the characteristics of a good
doctor.
837
Table 2
continued
Theme
Short description
Summary from interviews
VI
Knowledge
strategies and sources

for acquisition; critical
assessment; relationship
with practice.
This theme will be presented in detail in the

following pages, with quotes from the interview
transcripts and a few comments on them.
Detailed Presentation of Text Excerpts Related to the Theme of Knowledge

I grouped the text excerpts in three subsections; they reflect recurrent subthemes or trends in the interviews that usually coalesced after the interaction had developed for a while. Once again, for reasons of space, I had to
limit actual quotations to a bare minimum.
First Sub-theme: A Doctors Job is Never Done Knowledge is Never
Complete
This theme is commonplace in medical lore: there is a need to keep up-todate about what is on the cutting edge of medical knowledge, which is
assumed to be something that is growing all the time. At the same time, the
other 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 difficult. . . . Its impossible, especially now, with computers, the internet, with
. . . an increasing diffusion of computers . . . to keep updated. . . . its very
difficult, with all your activities, and outside the profession, your family,
your other activities, even your leisure, for you to arrange time for
reading, then you do what you can, but its very difficult. [Luis]
I mean, Im there on a daily basis from eight to five, and there are two
days that I go on straight until 8pm, at the outpatient unit. I have a weekly
shift here 24 hours. When will I study? When will I take a course? I cant,
I have to do it myself, isnt it so? On my own. [Marcos]
The other day . . . about a month ago I read a report . . . a quote in a
journal . . . that on the average two million new papers are published
worldwide . . . that means journals all over the world . . . thats per year,
two million papers. In terms of major cardiology studies, there are three
hundred great studies every year . . . theres no human being, in principle,
that has enough memory for all that stuff . . . per year . . . and has enough
time to read it all. [Milton]
The same ideas are present in the next excerpts. First it is Alberto, one
of the elder members of the group, who expresses in these words the large
amount of reading that he is doing himself, and which, presumably, should
be an indication of how much needs to be done on a regular basis:
I dont read medical journals, only. One day I read a journal, the other I
read a book. If you got . . . Im reading the Stein [book], which is a huge
838
book, this thick . . . Im reading it and Im going to read it from cover to

cover . . . Then, I, being a clinician, am going to read this book from cover
to cover, the same way Ive read many others, from cover to cover.
The need for constant updating is expressed even more strongly in this
excerpt:
. . . you force the student and there is no other word, its really force
to realize that he must be studying all the time, otherwise youll be . . .
youll become outdated . . . the drugs . . . its really crazy . . . the number of
drugs 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 triage
relevant/trustworthy/correct information from the multiplicity of sources
that constantly bombards them. The actual wording of the question varied
according to the unravelling of the interview. This usually produced the
most awkward situations: interviewees hesitated, grasped for words, ran in
circles, and at times hardly made any sense at all. I often had to rephrase
and reinstate the question several times before getting something from it,
and even then, in some cases replies were not exactly informative. Usually
I gave up pursuing the matter any further, for fear of inducing responses
out of excessive pressure. The most relevant aspect from the following
excerpts is that there is no single pattern to them. I chose the term
strategies rather than criteria because, in all cases, no explicit criteria
were apparent, and they presented their behaviour in terms of examples,
rather than as a methodical exposition of a set of rules. Actual strategies
varied from subject to subject, and were usually fuzzy and difficult to
explain. Personal preferences, convenience, bits and pieces of information
such as those derived from developments in epidemiology seemed all to
play variable parts in the composite strategies employed by the
interviewees.
Luis pointed to a mixture of personal interest, relevance for actual
practice, the relative authority of authors and journals, and a vague check
of methods:
. . . first you may try . . . an idea, you see? . . . see where this paper, this
work came from . . . [it also should be considered] . . . the method they
used, the . . . the importance that it has . . . then at times, you have themes
without . . . with very little interest to me. Such themes, or such subjects,
I wont . . . I wont pore over. Now, if its something that might have some
interest to me, or might have . . . might help me, youll make at least a
superficial reading of that, to check what its about, and then if its
interesting youll read the whole paper . . . [Luis]
Alberto mentions the practical interest and the cheats he uses as

shortcuts:
I get a journal . . . [unintelligible] I look at the papers abstract. I look at
the abstract . . . if the guy . . . is talking about something specifically, if its
839
clinical stuff, I read everything. Now, what will I read? I wont read . . . an
absurd, material and methods, as a general rule. I see it this way . . .
[Alberto]
In another excerpt, Alberto makes his position as a mere consumer of

knowledge totally explicit, even if intertwined with medical practice after
stating that research is important for generating new knowledge, he says
that 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 wont try to conclude anything, Ill get the conclusions that are
already 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 by
criteria . . . accepted by the scientific community. Then . . . depending on
the criterion, also the basis of the work . . . I believe in allopathic
medicine, I had my schooling in this direction . . . I have to start with a
randomized work, with criteria, controlled, published in a journal . . .
[hesitates] with an editorial, a decent reviewing committee . . . I think that
this is how it goes . . . a scientific work is one that follows norms
universally accepted by science . . . [Jorge]
Celia also emphasizes personal experience and makes interesting remarks

about the role
that reporting failures has in establishing credibility:
I also check . . . how many of these patients were unsuccessful. This is even
a way for you to lend credit to that research, at least I think so. Because if
you start out stating that your research was wonderful, was formidable,
theres something wrong with it. Could we be so bad at researching, that
we have so many mistakes, so many . . . losses, you see? Then I try to
check this. Theres always a lot of unsuccessful situations, and I think that
this gives it more credibility this is a bit weird . . . But I think it has more
credibility. [Celia]
Carla, the youngest interviewee, emphasizes the role

of personal preferences, but also of dislikes; she also mentions needs arising from practice:
I . . . first of all, theres a lot of personal interest into it . . . thats the first
thing . . . themes I like . . . Its the two extremes, stuff I like a lot and stuff
I totally dislike, but is the stuff that I force myself to study. Stuff that I like
a lot, like . . . textbook, and read a paper, journal . . . the New England . . .
and stuff I dont like, then, I get the textbook, read, read, read until I can
make sense of it . . . review papers, that also help to understand . . . and so
on. And the rest I fetch out of curiosity. Things that are fashionable also. I
dont have a very large private practice, but . . . things that turn out at the
office that we are forced to study, things that the patient . . . the patient
himself brings to us . . . [Carla]
Milton also talks about institutionally established sources of authority:
840
. . . [hesitating] We select . . . by the authors, the sources . . . whos

publishing it . . . the New England is the journal of the Harvard Medical
School. . . . [Milton]
Of all the interviewees, Roberto seemed the most disoriented by this

line of questioning, and referred vaguely to the role
of common sense as a
yardstick, but at the same time assuming it as an attribute or property of
individuals, rather than a learned skill:
. . . [hesitates] . . . I see that issue from the point of view of common sense
in medicine, and thats whats more important. That depends a lot on the
person whos practising, I dont 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, isnt it? Theres a lot of options. You
see, to prove aspirin as anti-adhesive for platelets . . . it was proven. There
were several other drugs which were not proven. Theres another slated for
release next year. Itll be released . . . thats what Im saying, anything can
come out of this . . . things change . . . [Pedro]
Luiza also stressed the importance of the journal that publishes the paper
as a source of credibility, but introduced a cautionary note:
Youll go after a paper, for instance, a paper from the Archives [of Internal
Medicine], you already have a certain basis of those who already did that
kind of treatment, based on . . . and thats why a clinician who is in the
wards, 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, but
that factor used worldwide . . . that routine, which conduct to be taken,
thats important. You dont have to know the last thing . . . but the last but
one, whats being done all over the world . . . [Luiza]
Alexandre was the only interviewee to mention the existence of forces that
have to be resisted when it comes to acquiring updated medical knowledge,
although even he did not manage to be particularly precise when it came to
proposing alternatives:
The pressure, the media, and so on . . . if this is something important or
not . . . if someone says this is the best available antibiotic . . . you have to
prescribe this antibiotic, it cures everything, heres the bacteriology . . . I
think that the individual needs something like . . . the need for this critical
appreciation, you do not accept immediately . . . an evidence, even what is
your knowledge . . . some journals that try to filter some things, which are
not exempt from pressure . . . I think that clinical epidemiology is a
weapon that you need to provide data for the patient, for the doctor so
that he can make certain decisions. [Alexandre]
Third Sub-theme: It Aint Necessarily So Scepticism and Mistrust

In the previous subsection, a common trend of delegation can be seen in
the excerpts instead of criteria of validity, there is an implicit accreditation placed on certain sources, mostly institutional, particularly certain
841
journals; the New England Journal of Medicine shines brightly as a consensual symbol of cognitive authority. From these it would seem that the
interviewees are content to play a passive role
when acquiring knowledge.
Not so. The following set of excerpts shows several reasons for not taking
such information at face value, and reinstating once again the role
of
personal experience in the process.
Roberto mentions the risk of relying on knowledge that is inherently
unstable:
. . . we cannot base our conduct on a paper that just came out, because
next week there might be another proving just the opposite, then we have
to be extremely cautious. There are some consensus panels that some
[medical specialties] societies do . . . consensus on the treatment of
hypertension, consensus for lipid disorders . . . which is the most discussed on this issue in cardiology . . . and even these consensus results
cannot be applied, because its 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: thats what Im talking about, theres no use in
reading too much, todays truth is tomorrows lie . . . Isordil for heart
failure . . . when it was introduced, it was like that: every hour and a half
you had to administer a sublingual capsule . . . Now you see that . . . with
use of the medication [unintelligible] . . . How many drugs you see that
are introduced, in the beginning as miracle drugs and then . . . disappear
. . . a few years afterwards. You see that a lot, its not just a few cases, its a
lot. Whats the use of a book that comes out every two years . . . theres
a lot that was lost and was not for too long because it was not scientifically
proven 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 the
guy do? OK, gases. Alright, lets study gases. But do you know why
the 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 gets
published . . . any rubbish gets published. [Alberto]
And in this next excerpt, Alberto illustrates how medical perception can be
biased by theoretical conditioning, establishing very different roles
and
expectations for the researcher and the clinician:
If [a doctor] only reads myocardiopathy, thats all hes going to see.
Everything that turns out in front of him from that moment hes trying to
learn about it on is myocardiopathy . . . Then I think that a doctor has
to read everything. . . . Unless hes a researcher. When hes a researcher on
disease and pericardial diseases, then hell only read pericardium . . .
[Alberto]
These excerpts demonstrate that even when physicians recognize the

epistemic authority of scientific sources namely, research and published
842
papers they recognize inherent characteristics that preclude an immediate transposition of what is published to actual medical practice,
either because recent knowledge is also unstable knowledge, or because
relevance criteria differ between the scientific arena and their daily practice. A second thread of argument, not exactly like the preceding one, but
closely intertwined with it, is concerned with the rle played by the
pharmaceutical industry and its marketing strategies.
Celia strikes a similar note, raising additional reasons for taking results
from papers with a grain of salt. She is speaking ironically about new drugs
that are released to the market:
Theyre all wonderful, arent they?. . . Oh, its so good . . . perfect, marvellous, and all that . . . Then youll want your own experience, to know
whether for your population, if that drug was good . . . how to achieve
this? Of course theres the literature, theres someone who researched
3000 patients using that drug . . . but sometimes its your patient who is
the one where it wont work, but its a starting point . . . You wont always
think that . . . that its just advertising of the drug companies, and so on,
but sometimes it does not work, Brazilian patients, you see . . . these
researches are . . . USA, Europe, the biotype is different . . . the socioeconomic status is different too . . . But I think that this is the way we do it
here . . . [Celia]
Marcos spells out the biases introduced by the pharmaceutical industry

and the need of personally checking claims of effectiveness:
We get a patient in the ward, and we use that drug that has been
introduced to the market for two, three months and we begin to apply it in
the ward. Then you see in loco the created situation, youll see if thats just
a fiction created by the pharmaceutical companies or if its really
effective.
Celia, once again, is even more explicit in describing the role

of the
pharmaceutical industry in shaping medical knowledge, in this passage:
You attend to a lecture where he says that the best drug to use against high
cholesterol levels is X . . . then you look into it, he didnt compare it with
anything, you know, and in fact . . . Why did he say it was X? Because he
was funded by a drug company. That is . . . this is due to . . . this has to be
written in the research reports, that you did it for the X, Y or Z drug
company. The . . . I think it gets a bit biased when the drug companies are
behind 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 . . . the
patient is there . . . you wont administer a last generation inhibitor . . .
betablocker, nothing like that, because thats not our option . . . you know
this . . . youll see a lot of patients, youre consulting everyday . . . youre
receiving the guy from the drug company marketing placing lots of free
samples there. [Luiza]
843
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 are
reinforced:
1. These doctors are not scientists, they are not involved in producing
knowledge according to the institutional practices of science, and are
consumers of knowledge produced elsewhere. It might be argued that
this derives from the fact that Brazil is a country with far less resources
than the most developed ones, but preliminary results from interviews
conducted with Canadian doctors indicate otherwise;
2. The lack of differentiation between the roles
of physicians and professors in that institutional setting (the University Hospital), as well as
the lesser importance attributed to other academic degrees, is important evidence of the placement of medical education as part of the
broader medical field.
A major issue is that of the perceived informational overload what I
would call the Sisyphus Effect. Doctors lack of spare time, at least in this
group, is an indisputable fact,9 as is the sheer volume of new publications
poured continuously through an ever increasing number of journals. But
what might seem a next logical step, the commonsensical notion that
medical knowledge is increasing at a dazzling pace, making everything
change almost overnight, must be carefully considered.
This was evident in the quoted interview excerpts, but more examples
can be found almost everywhere without much effort. The clinical textbook quoted from earlier, Harrissons Principles of Internal Medicine [Isselbacher et al. (1994)], has in its opening pages a disclaimer, encouraging
readers to confirm the information it presents with other sources. That
note begins with the following sentence: Medicine is an ever-changing
science. 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 we
know and understand them, create frequent, major changes in the way
that we care for our patients. Second, it is increasingly clear that, although
we need (and our patients would benefit from) this new evidence daily, we
usually fail to get it. Third, and as a result of the foregoing, both our upto-date knowledge and our clinical performance deteriorate with time.
Fourth, trying to overcome this clinical entropy through traditional continuing medical education programs doesnt improve our clinical performance. . . . [Sackett et al. (1997): 5]
The idea of progress of science and medical advances could be

challenged on several grounds, but even if we take these for granted, how
frequent and major are the changes that they bring about? A study of
innovation in medicine is far beyond the scope of this paper [an example
of 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.
844
The bulk of innovation, both in terms of medical equipment and

drugs, comes currently from the private sector.10 This means that economic forces play a major role
in such dynamics, and should be taken into
consideration when analysing such changes in medicine. These markets
have a limited number of players, high-tech companies that are part of
large transnational corporations. In such situations, competition usually is
not price-based. Considering the sheer volume of resources these corporations have, a price war could rage for too long, and cause too many
economic casualties, possibly turning even the eventual winners final
triumph into a Pyrrhic victory. In such situations, companies compete
through 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 emphasizing
minor differences between products from different companies, but also
promoting successive versions in a line of products from the same company. The temporal evolution of product lines in the auto industry and in
some branches of consumer electronics, such as audiovisual equipment,
provides concrete examples of such strategies. Going back to medical
industries, there is a further element to be considered: patents. Copyrights
and protective legislation are effective shelters for securing revenues in
certain market niches.
Analysing innovations in medicine from this angle, frequent, major
changes seem less likely. Products have a life cycle, and introducing new
products in the same categories in which old ones have not yet fully
realized their profit potential becomes an unlikely scenario. A steady flux of
innovations, which are either frequent or major, but rarely, if ever, both at
once, makes more economic sense. Reinforcing the idea that innovations
occur at such a breathtaking pace, however, can be an extraordinarily
effective marketing strategy. This is a point that will be fully addressed later
in this section, but, for now, what needs to be stressed is that this brief
incursion into microeconomics gives at least some reason for taking claims
about continuous revolutions in medical technology with a grain of salt.
With regard to notions of progress, we should also note the absolute
dominance of English-speaking publications (both journals and textbooks)
as the references for the interviewed doctors. This dominance is so overwhelming that many of the interviewees used an expression to refer to
textbooks livro-texto which is a literal but meaningless translation into
Portuguese 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 interesting
aspect in the way that they surfaced in the interviews. Considering that we
were discussing a routine operation in their daily lives, the fact that the
interviewees were at a loss to explain it is particularly intriguing. There is
an interesting analogy here with the description of diagnostic strategies
presented by Sackett et al. (1991), especially with pattern recognition.
According to these authors, a key component in medical diagnosis is the
immediate recognition of characteristic clusters of signs, which are grasped
845
as a whole, and not analytically one by one. The interesting thing to note is
that they say that, although an ex post facto reconstruction of a stepwise
procedure may be described by the doctors, it does not describe what
actually happens in practice. The actual mechanism of pattern recognition
takes place far too quickly for any deliberative procedure. This is in line
with Ginzburgs conjectural paradigm [Ginzburg (1980)], which could also
be described as a form of pattern recognition. It could thus be hypothesized that doctors employ similar strategies to sort out information when
seeking to update sources they use when diagnosing, quickly selecting
certain elements and reconstructing them in a gestalt. The difficulty they
experience in explaining such procedures would may arise from the fact
that they are not following a flowchart when executing their strategies, but
operating on a much more intuitive level.11 This observation also lends
weight to the hypothesis that ordinarily doctors are not fully competent to
evaluate scientific journals. If this were the case, more definite, fully
conscious and systematic procedures could be expected.
The issue of competence demands some clarification. We can distinguish at least two separate epistemic cultures, to refer once again to
Knorr Cetinas expression, within the field of biomedical research: laboratory experiments and epidemiological validation. The first is characteristically related to hard sciences such as molecular biology, and provides
general frameworks for explaining why certain drugs work the way they do,
or how pathogenic agents produce the features of specific diseases. These
explanatory models are, to a large extent, irrelevant to actual medical
practice, since a doctor does not need to know anything about quantum
mechanics, for example, to interpret the result of a MRI scan. Epidemiological validation, however, has a decisive influence in defining standards
for medical practice. Marc Berg, for instance, shows how medical practice
has been reshaped over the last two decades by the introduction of several
standardized protocols [Berg (1997)], and Ilana Lwy discusses the importance of randomized clinical trials for the introduction of new drugs in
general, and particularly in the treatment of desperate medical conditions
[Lowy
(2000)]. In both cases, it would seem reasonable to expect that

doctors would understand the reasoning that leads to stating that drug A is
preferable to drug B, or that exam Y should be requested when conditions
X, W and Z are present. Unfortunately, such expectations are often not
met, in practice, and Evidence-Based Medicine, for instance, capitalizes on
this insufficiency.
It is also possible to derive a hierarchy of sources of knowledge from
the interviews. At the highest level, as the most important source, lies
personal experience. Such experience includes bedside learning for medical
students. For doctors, it is more than hands-on, lived-through professional
experience, because such learning is often acquired by proxy through
continuous interaction with colleagues and even students. On the second
level, there is textual information. There are three subcategories in this level:
journal papers, textbooks and the internet. The internet is the most
dynamic and convenient source, although not necessarily the most reliable,
846
whilst books may be seen as inherently outdated, but also rock-solid when
it comes to proven knowledge. Papers occupy an intermediate position.
These findings are strongly similar to Flecks description of varieties of
scientific communication quoted in the beginning of this paper, with two
important exceptions: the first is obviously the internet, which was not
available in his time; the second and most intriguing is the lack of reference
to introductory handbooks. A possible explanation for this is that there are
actually no clear-cut differences between textbooks (vademecums) and
handbooks (manuals) in clinical medicine.
Although there is consensus among the interviewees about the characteristics of each of these textual forms, the relative ranking of the importance of the different forms varies considerably depending on who was
interviewed. Some of the younger doctors tended to rely more on the
internet than the older ones, but this was not always the rule. The most
enthusiastic 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 less
critical about the internet than, for example, Luiza. Some recurrent
expressions also exhibit gradients, even within the same subcategory. For
example, footnotes in textbooks may be held superfluous, and the contents of latest papers may be regarded as unstable and risky. Both are
associated with the bookworm type of doctor, more concerned with
theory than practice, a stereotype with which none of the doctors wants to
be associated. Both the stereotype and its repulsiveness are strong evidence
of the epistemological primacy of experience for doctors. Doctors also
employ a clearly pragmatic, result-oriented approach, sometimes to such a
degree that they dispense altogether with the need to know the methodologies employed in the studies. By the same token, the doctors interviewed do not assign much importance to information from the so-called
basic sciences. They do, however, rely on personal and/or institutional
markers of epistemic authority as selection criteria. Foreign books in their
original language are more trusted than locally produced or translated
versions. As mentioned previously, the New England Journal of Medicine is
unanimously acknowledged as a symbol of excellence. Curiously, Christakis et al. (2000) claim that no such bias was observed in a study they
conducted, even though the artificial situation created in their experiment
was completely different from actual practice. Christakis and his colleagues
handed papers from two journals to their subjects. Through no coincidence, one of these journals was the NEJM. They disclosed the name
of the journal in some cases and not others, and subjects were asked to rate
them. After discussing limitations present in their research design, they
summarize their results with the following remarks:
These limitations prohibit us from concluding that journal attribution
bias does not exist. Nevertheless, our results are encouraging. They
suggest that given the opportunity and the dedication necessary to review
an article or abstract carefully, physicians regardless of their formal
training in epidemiology or biostatistics are able to read articles without
847
significant or large discernible bias based on publication source. [Christakis et al. (2000): 777]
The problem lies precisely in the fact that doctors lack the time to carefully
review everything, and they select papers based on the reputation of their
sources before they read them.
Finally, at the lowest level of the hierarchy lie passive oral communications: congresses, symposia, lectures, and meetings sponsored by the pharmaceutical industry on drugs being introduced (more on that later). These
are passive from the point of view of the interviewees, and should not be
confounded with learning by proxy, which is the result of systematic
interpersonal 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 a
legitimate 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 impossibility due to the doctors busy lives. There is considerable overlap between
the levels of this hierarchy and the findings of Fernandez et al. (2000), who
studied similar sources of knowledge in medicine.
The last issue to be assessed in this section is the scepticism elicited in
the interviews. Medical scepticism is nothing new; in fact, therapeutic
scepticism is used as a label to identify a period in medical history (the late
19th century) during which most of the basic theoretical underpinnings of
modern medicine were in place, although no modern therapeutic options
were yet available. Doctors were then, as now, sceptical about their
pharmacopeia, yet had no other choice but to use them. Although presentday doctors may have more reason for trust than their 19th-century
counterparts, they also lack alternatives that would fully empower them to
pursue their mistrust to its fullest extent. Going back to the economic
argument previously presented, it should be noted that the production of
medical knowledge, or more precisely, the production of knowledge with
possible medical uses, is also part of the same economic dynamics. Since
the research is produced mainly by private sector companies with huge
economic interests at stake, there is a disproportionate concentration of
power on one side of the trade. These companies produce the knowledge,
funded through advertisements in the main journals. The journals also are
edited by large publishing companies, which are, in a sense, part of the
same sector of the economy. (The same can be said about the most
relevant textbooks.) Drug companies fund medical symposia and congresses and even subsidize individual doctors to attend such events. The
sponsors use such meetings to introduce new drugs, which have a curiously common mise-en-sc`ene: a renowned specialist is invited to present the
new drug, usually in a luxurious setting like a top-ranking hotel; during
the presentation, the invited authority never refers to the new drug by its
commercial brand, but only by its chemical name, although the venue is
usually literally covered with signs and posters prominently depicting the
848
products and the drug companys names. Finally, the most continuously
operated strategy involves the deployment of armies of marketing agents
from the pharmaceutical industry, who swarm around hospitals and clinics
and deliver free samples and gifts. Such practices have been demonstrated
to 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 in
and through the marketing practices of the pharmaceutical, equipment and
publishing industries. There is a solid body of literature produced in Latin
America, especially Brazil, from the early 1970s to the present [unfortunately, many of these sources, such as Cordeiro (1980), are not
translated into English], focusing on the so-called medical-industrial complex. This expression, coined after Eisenhowers famous remarks on the
alliance between military, political and economical interests in the USA, is
used to characterize the modern development of medicine in its relation to
industry. The analogy attempts to demonstrate that (a) medical needs are
not spontaneous, but heavily induced by the supply of health care services,
and that (b) economic interests tend to favour the deployment of such
services so as to maximize profit, with no direct relation to actual needs of
populations, especially the poorer sectors. This should not be mistaken for
a facile conspiracy theory: at issue is a configuration of mutually influential
institutional developments within capitalist societies. The medical profession, its schools, teaching hospitals, the pharmaceutical industry, the
medical equipment industry, technical publishing companies, all originated in different places and times, but developed as intimately interrelated
institutions, forging a network of strong social, economic and epistemic
links. Similar ideas are expressed by Blume, who interestingly also mentions Eisenhowers original expression [Blume (1992): 55].
Such an array of forces will inevitably introduce important biases into
medical knowledge and practice, as demonstrated by, among others, Stern
& Simes (1997), who found evidence of publication bias favouring publication of papers with positive evaluations of treatments; Friedberg et al.
(1999), who describe a similar situation with regard to cost-effectiveness
studies, in a paper that prompted an editorial comment urging more strict
guidelines for the submission of cost-effectiveness studies for publication
[Krimsky (1999)]; and Stelfox et al. (1998), who demonstrated a correlation between links to the pharmaceutical industry and sides taken on the
debate about a specific drug. While DiNubile (2000) deplores this situation
as a result of doctors being insufficiently sceptical, this does not seem to be
the case, necessarily. The sceptical stance of the interviewees in my study
was clearly evident and well argued. Almost all interviewees provided
examples compelling anecdotal evidence of cases in which guidelines
were not strictly followed and therapeutic success was achieved, anyway,
and they also described the converse situations in which strict adherence to
guidelines did not result in success. However, doctors lack resources
to fully pitch their scepticism against the massive forces of the medical
knowledge industry. This is not much different from the situation of the
849
hypothetical dissenter described by Latour [(1987): 21100], who keeps

challenging scientists claims, only to be finally silenced by the dazzling
array of resources that the latter can enrol in their support. No matter how
sceptical, in the end the doctor has no choice but to give in.
There are two possible objections that need to be addressed at this
point. First, it could be argued the interview responses do not describe the
doctors actual practices. Second, since the interviews address only general
practitioners, it could be argued that they do not necessarily represent the
views of specialists, particularly those in the more high-tech areas of
medicine.
With regard to the first objection, it should be noted that the interviewing strategy was designed so that respondents would not know the
actual 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 of
the study (the detailed results are not presented in this paper). Putting
together both legs of the study, a total of 24 interviewees from 2 different
institutions, facing 2 different interviewers, provided consistent responses.
Finally, even if interviewees were, in the worst possible case, grossly
misconstruing their opinions, beliefs and deeds in the interviews, that
misrepresentation would still be based upon presumably correct approaches, indicating the shared values that are actually more important to this
study.
With regard to the second objection, I would emphasize once again the
role
of the interviewees in forming opinions, given their pre-eminence both
as doctors and professors, particularly in the second role.
They contribute
heavily to shaping of the views of future doctors, general clinicians and
specialists alike. It should also be noted that, although the interviewees are
all professors of internal medicine, this does not mean that they have
not specialized in other fields. As a matter of fact, most of them are also
specialists, even in high-tech areas.
The exploratory nature of this study was mentioned at the beginning
of this paper. Additional research is necessary before the conclusions that
follow can be widely extrapolated. As noted, another set of interviews, still
being analysed, was conducted with Canadian professors, and an ethnographic phase of the study is still under way. Another research project,
related to the one reported here and dealing with similar issues in cardiology, is still being carried out. In any event, this is, as it has been previously
stated in this text, an area that demands more attention than it has received
so far.
Conclusions: Consequences of a Particular Thought Style

To put this study in perspective, it is important to go back to Flecks
general framework in order to assess how well his categories apply to what
is being described here. I believe that at least his two basic constructs are
strongly relevant: the doctors in this study are part of a community that
maintains systematic intellectual interaction, thus qualifying as a thought
850
collective; and the interviews at least hint at the existence of certain

constraints on thought that make doctors see things in specific ways while
excluding others. For instance, despite having qualms about specific drugs,
particularly newly introduced drugs, there is no question that drugs are a
major (if not the major) tool for dealing with health problems. The strong
tendency 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 of
authority which are outside the reach of their own experience adds strength
to the idea that they are included in the exoteric circle, if not the core
esoteric group of researchers who are recognized experts in the research
area.
The thought style that emerges from this set of interviews can be
briefly characterized as a largely intuitive,12 pragmatic, result-oriented
search of relevant (that is, potentially useful in practice) information,
selected from sources with sufficient academic credibility. Further, the
thought style emphasizes the primacy of practical, experiential knowledge,
and expresses a sceptical stance, at times bordering on cynicism, toward
the latest innovations. Despite this scepticism, however, doctors lack
resources (namely, time, knowledge of technical aspects of research, particularly in terms of epidemiology and statistics) to effectively assess
knowledge that 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 another example of the type of perceptual
coercion produced by a thought style and, on the other, by the vastly
disproportionate forces available to those who effectively produce and
distribute such knowledge.
The net effect of this situation is the receptivity of the medical
profession to the pre-digested and pre-selected information presented by
the industrial side of the medical-industrial complex. Sheldon Rampton
and John Staubers book on the strategies of corporations to enrol scientists support to their PR interests quotes a number of clearly documented
cases in which several companies, from tobacco to pharmaceutical industries, were able to hire scientists to produce (or, in the worst cases,
simply sign) papers reflecting their interests that were published in prestigious journals, even the NEJM [Rampton & Stauber (2000): 20004]. The
same book documents how sources of funding bias research protocols and,
consequently, their outcomes [ibid.: 21721]. Doctors pursuit of up-tothe-minute knowledge, one of the features of their thought style, is
acknowledged and used by the medical knowledge-industry to its advantage. Currently proposed remedies, such as the adoption of strategies
based on the so-called Evidence-Based Medicine have among other
shortcomings the failure to acknowledge the extensive social, economic
and 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 clinical
method which emphasizes individual cases, and further reinforces their
851
epistemic dominance by a discipline that they usually do not fully grasp. As

Isaac 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 terminology, might be understood by no one and yet believed by everyone [Asimov
(1991): 5].
The healthy scepticism of the doctors needs resources to match the
forces it opposes. The production and diffusion of medical knowledge are
thus also public health concerns, and as such should be addressed by
public policy, and, especially, more strongly funded by the public sector.
Going back to the question formulated at the beginning of this paper, the
way doctors evaluate knowledge is mostly intuitive and dependent upon
authoritative sources. Consequently, doctors would certainly benefit from
additional resources that can help them to perform this task.
Notes
This work was made possible by grants from Brazils National Research Council (CNPq),
the Brazilian Education Ministrys Committee for the Development of Human Resources
(CAPES), and Rio de Janeiro State University (UERJ). The author wishes to express his
deepest thanks to McGill University, its Department of Social Studies of Medicine, and, in
particular, to Professors Allan Young and Don Bates, without whose help this paper would
not exist. This paper is dedicated to the memory of Professor Don Bates.
1.
2.
3.
4.
5.
6.
7.
For a detailed account, see Fleck (1979) and also Cohen & Schnelle (1986), a book
that presents some of Flecks previous papers and critical assessment and commentary
by a variety of authors. On Flecks relevance to contemporary studies in science and
medicine, see, for instance, Hacking (1999): 60, and Kuhn (1979), (1996): viiiix.
Fleck refers to Durkheim in his book [Fleck (1979): 46], albeit criticizing him,
alongside others, for their . . . excessive respect, bordering on pious reverence, for
scientific facts [ibid.: 47].
Although for reasons of space this issue will not be dealt with in this paper, Michel
Foucaults archaeology of knowledge is also relevant to the discussion: see Foucault
(1972), for his own critical reappraisal of his previous writings. A comprehensive
account of Foucaults work up to and including the Archaeology can be found in
Gutting (1989).
Even though I stand by these remarks, the current stage of this research involves the
direct observation of the interactions between a professor and final-year medical
students and residents. This ethnographic research is useful for the purpose of
establishing triangulation between the results produced by different techniques.
The actual name of the University is not given, for reasons of confidentiality.
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 more
interviews were conducted by a research assistant under my supervision. Although the
second set of interviews is complete, it will not be presented in this paper, except for a
brief discussion in the conclusion. Another set of interviews was conducted in Canada,
but its analysis is not yet finished.
I presume that the knowledge that the interviewees had of my own previous
institutional affiliation, that of a staff member in the medical psychology unit in the
University Hospital, may have had an important influence on their responses, since
they 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 the
interviews stressed the importance of humanitarian values for the profession. They were
never specific about exactly what that meant, how they would be translated into
852
practice, whereas with regard to other aspects of medical practice they provided ample
clarification, examples, case anecdotes, and so forth. Obviously, there are technical
aspects to dealing with human emotions and subjectivity, but this does not seem to be
acknowledged by the interviewees (perhaps I should say by the medical profession as a
whole), who trust vague common sense to deal with such matters. There is a contrast
between how much theoretical knowledge the interviewees seemed to consider as
required when prescribing a drug, for instance, versus counselling and similar soft
approaches to care, so the statement that such items were important for the medical
profession was contradictory.
8. Another point worth mentioning is the use of male pronouns throughout the
interviews. Although Portuguese is a gendered language, in the sense that possessive
nouns, substantives and some adjectives have suffixes indicating gender, in situations
where gender is not known or not important (for instance, when giving an example
about a generic doctors actions) usage of the equivalent pronouns to he and him, as
well 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 words
were retained in the translation. It should be noted that this observation is not in any
way specific to the interviewees, applying generally to the way that Portuguese is spoken
and written, at least in Brazil.
9. It should also be noted that all interviewees had at least one other job besides the
University position, also a common situation in Brazil; this is linked to the patterns of
the 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 of
Sciences on the evaluation of health care interventions [Warren & Mosteller (1993)], in
which major proponents of EBM were keynote speakers, managed to steer clear of this
rather obvious fact.
11. An alternate explanation to their hesitation when asked how they actually keep up with
the development of medical knowledge was proposed by one of the reviewers of the
first 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 actually
manage to read. Although I cannot rule out this explanation, I do not think that this
was the case, mainly because the question was not posed in such a way as to point to
how much one should read, but how reading should be prioritized.
12. The importance of intuition in medical practice is stressed both by Fleck (1986) and
Ginzburg (1980).
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Address: Instituto de Medicina Social, Universidade do Estado do Rio de
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20559900, Brazil; fax: +55 21 2264 1142 or +55 21 2569 3077;
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ABSTRACT The differential selection and assessment of knowledge is a key feature of

epistemology, medical anthropology, medical knowledge, thought style

The Thought Style of Physicians:

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medical knowledge is an integral part of medical practice; this is clearly an

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special carrier for the historical development of any field of thought, as

and the second as . . .

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ethical principles [Canguilhem (1978): 134]; even though a description of

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discovery). Non-scientist readers of these magazines are analogous to

Extrapolating from Youngs distinction, my contention is that physicians

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present in other forms of discursive production,3 as speech itself. In this

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Rochel de Camargo: Thought Style of Physicians

at least three different kinds of interaction could be postulated beforehand

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Rochel de Camargo: Thought Style of Physicians

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Summary from interviews

There is a diffuse dissatisfaction among the

Personal participation in research activities is

Even for those who did have a graduate degree

Although in theory one could draw a precise

All the interviewees highlighted the relevance of

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Summary from interviews

strategies and sources

This theme will be presented in detail in the

Detailed Presentation of Text Excerpts Related to the Theme of Knowledge

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book, this thick . . . Im reading it and Im going to read it from cover to

Second Sub-theme: Looking for Needles in Multiple Haystacks

Alberto mentions the practical interest and the cheats he uses as

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In another excerpt, Alberto makes his position as a mere consumer of

Jorge produced, after great insistence, a vague description of standards,

Celia also emphasizes personal experience and makes interesting remarks

Carla, the youngest interviewee, emphasizes the role

Milton also talks about institutionally established sources of authority:

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. . . [hesitating] We select . . . by the authors, the sources . . . whos

Of all the interviewees, Roberto seemed the most disoriented by this

But Pedro is straightforward: it is important to have scientific that is,

Third Sub-theme: It Aint Necessarily So Scepticism and Mistrust

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

Alberto makes a penetrating critique of the effects of publish or perish