Abstract
The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and uncertainty as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh’s taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case analysis is further developed by the use of the Canadian philosopher Bernard Lonergan’s theory about understanding and objective knowing. According to Lonergan it is not by getting rid of or even by reducing uncertainty, but by attending systematically to it and by relating to it in a self-conscious way, that objective knowledge can be obtained. The paper concludes that uncertainty is not a regrettable and unavoidable aspect of decision making but a productive component of clinical reasoning.
Highlights
More than 20 years ago while one of the authors (KH) was working as a clinician on an acute hospital ward, she had an experience she has since reflected on again and again
The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research
EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement
Summary
More than 20 years ago while one of the authors (KH) was working as a clinician on an acute hospital ward, she had an experience she has since reflected on again and again. The first piece of data given to her apart from the basic initial details is the interpretation of a colleague in the trauma team: be prepared for a cerebral hemorrhage Kristin starts questioning this information based on heuristics, i.e. already acquired knowledge about similar conditions. This way she is starting the process of defining what she does not know, while at the same time directing her mind towards a possible answer. With Kristin’s reverse insight a new set of questions is launched (Maybe it is a suicide attempt or deliberate self-harm?) and with these questions, old data gain new meaning (the young man being unconscious due to drug related overdose) and new images call for interpretation (the father’s unwillingness to give information about his son’s condition for instance). Rather is it a judgement which is absolute in the sense that it takes all aspects—certainties as well as uncertainties—into account
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