We elaborate the article Clinical judgement and the medical profession written by Guver S. Kienle and Helmut Kiente, that talks about the clinical judgement into the medical profession. The essay also explains the concept of Technical Rationality, the corresponding model of professionalism, conceiving intelligent practice as application of external science: the practitioner hands his problem over to the external scientist, who, after having solved the problem, returns scientific knowledge and scientific directions to practice.
The model of Technical Rationality shifts emphasis from the patient–doctor relationship to the client–provider contract. The practical realization of this model leads to extensive external regulation of the doctor’s activities, to diminishing autonomy, deprofessionalization, proletarianization and over-management of medicine. Consequences are an overwhelming bureaucratic work load, restricted expert performance, and minimized time for the individual patient. In many countries, doctors feel utterly demoralized by their situation.
Still, in contrast to the positivists’ theory and ideal of Technical Rationality, the practice of the medical profession has often been described as a combination of practical science and artistry. The model of Technical Rationality has been shown to be grossly oversimplified and applicable only to simple, repetitive and novices’ situations, but not to the complexity which generally characterizes real-life professionalism. For a more elaborate epistemology of professional practice several further traits, in addition to external knowledge, are characteristic –tacit knowledge, reflection in action and Gestalt cognition.
Tacit knowledge (implicit knowledge) generally constitutes much of expert knowledge. Experienced and competent professionals do not only rely on explicit factual knowledge but also on tacit knowledge. The competent practitioner makes innumerable judgements of quality for which he cannot state adequate criteria, and he displays skills for which he cannot state the rules and procedures. Practitioners know more than they can say, and it is the tacit knowledge which distinguishes the master from the apprentice. Experts’ knowledge with its striking flexibility, sensitivity to context and individual orientation cannot be replaced by formalization. This also applies to scientific discovery: the abilities to see a problem, to anticipate the unknown, and to find a new route to insight and knowledge are all based on tacit dimensions.
Reflection in action becomes relevant when the practitioner deals with a situation of uncertainty, instability, uniqueness and conflicting values. When confronted with problems for which explicit guidelines or implicit knowledge are insufficient, or when spontaneous performances yield unexpected results, the practitioners can become researchers in their own practice. They enter into a reflective conversation with the situation in order to a find solution. Open for the discovery of new phenomena, they become artistic and creative, and can eventually produce new insight and knowledge. Through reflection, they can also surface and criticize the tacit understandings that have evolved around repetitive observations and around guidelines. In this way, reflection can serve as a corrective to overlearning.
Gestalt cognition assesses the wholeness of a pattern that is irreducible to its parts and conceivable independent from its particulars. While stochastic approaches assess correlations, Gestalt-oriented approaches assess patterns. Personal experience can transform into Gestalt cognition, which can be recast into the logic of tacit thought, and can eventually be manifested even in the tacit power of the scientific or artistic genius. It is this capacity for Gestalt cognition which enables the expert’s connoisseurship, that is, his exceptional ability to swiftly interpret situations and to exhibit outstanding performances. Gestalt cognition also promotes the capacities for reflection in action.
An important question is whether these features of professionalism are of any relevance to the judgement of therapy effects. The answer must be definitely negative, that is, as long as David Hume‘s dictum is held to be true: as long as single case causality assessment is considered as principally impossible. Yet, the school of Gestalt theory, and also other epistemologists, raised opposition against Hume’s doctrine and pointed at novel ways to causality recognition which are also relevant for medicine.
