Clinical intuition versus statistics: different modes of tacit knowledge in clinical epidemiology and evidence-based medicine

Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension from clinical judgment. This is demonstrated through analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine’s epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi’s theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine.

Cultural competence and evidence-based practice in mental health services: a complementary perspective

The need for cultural competence and the need for evidence-based practice in mental health services are major issues in contemporary discourse, especially in the psychological treatment of people of color. Although these 2 paradigms are complementary in nature, there is little cross-fertilization in the psychological literature. The present article illustrates the complementary nature of these 2 paradigms. A main point of convergence is related to the development of culturally adapted interventions in the move from efficacy research to effectiveness studies. The implications of cultural adaptations of empirically supported treatments for mental health services in terms of research and practice with ethnic/racial minority populations are discussed.     

Expertise in evidence-based medicine: a tale of three models

Background

Expertise has been a contentious concept in Evidence-Based Medicine (EBM). Especially in the early days of the movement, expertise was taken to be exactly what EBM was rebelling against—the authoritarian pronouncements about “best” interventions dutifully learned in medical schools, sometimes with dire consequences. Since then, some proponents of EBM have tried various ways of reincorporating the idea of expertise into EBM, with mixed results. However, questions remain. Is expertise evidence? If not, what is it good for, if anything?

Methods

In this article, I describe and analyze the three historical models of expertise integration in EBM and discuss the difficulties in putting each into practice. I also examine accounts of expertise from disciplines outside of medicine, including philosophy, sociology, psychology, and science and technology studies to see if these accounts can strengthen and clarify what EBM has to say about expertise.

Results

Of the accounts of expertise discussed here, the Collins and Evans account can do most to clarify the concept of expertise in EBM.

Conclusions

With some additional clarification from EBM proper, theoretical resources from other disciplines might augment the current EBM account of expertise.

     

Psychotherapy,complementary and alternative medicine and social dysfunction

This article investigates a bio-psycho-social approach to psychotherapy which works, where possible, with interdisciplinary complementary and alternative medicine teams. The model, called anthroposophic psychotherapy, sees body, soul and spirit as interconnected and the study discusses the bio-psycho-social aspects of the model by linking cardiovascular disease, psychological stress, asocial behaviour and social dysfunction utilizing single case study methodology. The limitations of this method are acknowledged and discussed, but it is also argued that the study has a valuable part to play in a research programme which may also later include efficacy and effectiveness research. The methodology incorporates the principle of data synthesis, as well as data analysis, in accordance with the holistic nature of the clinical model, since it takes the view that all of the elements in the research field are connected. The anxieties presented by the client were linked to arteriosclerotic symptoms and social problems. All of these elements had their roots in childhood and needed to be treated with a number of interventions, including anthroposophic psychotherapy and medicine, which incorporates the homeopathic principle of ‘like cures like’.     

Clinical wisdom in psychoanalysis and psychodynamic psychotherapy: a philosophical and qualitative analysis

To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons "wise." Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle's intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the practice of psychoanalysis and psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom.     

Biases in intuitive reasoning and belief in complementary and alternative medicine

Very little is known about the reasoning underlying beliefs in complementary and alternative medicine (CAM). This study examined whether CAM beliefs can be better explained with intuitive reasoning, paranormal beliefs and ontological confusions of physical, biological and mental phenomena than with 12 variables that have typically been used to explore the popularity of CAM, namely gender, education, income, age, health, desire to control treatment, satisfaction with conventional medicine and world view (unconventional, feministic, environmentalist, exotical and natural). A representative sample of Finnish people (N = 1092) participated in the study. The results showed that intuitive thinking, paranormal beliefs and ontological confusions predicted 34% of the variation in CAM beliefs, whereas the 12 other variables increased the prediction only by 4%. The results help to explain individual, cultural and situational differences in the popularity of CAM and to differentiate between CAM statements that can be scientifically examined from those that cannot.     

Attitudes towards complementary and alternative medicine among medical and psychology students

The use of complementary and alternative medicine (CAM) is increasing in Europe as well as in the USA, but CAM courses are infrequently integrated into medical curricula. In Europe, but also especially in the USA and in Canada, the attitudes of medical students and health science professionals in various disciplines towards CAM have been the subject of investigation. Most studies report positive attitudes. The main aim of this study was to compare the attitudes towards CAM of medical and psychology students in Germany. An additional set of questions concerned how CAM utilisation and emotional and physical condition affect CAM-related attitudes. Two hundred thirty-three medical students and 55 psychology students were questioned concerning their attitudes towards CAM using the Questionnaire on Attitudes Towards Complementary Medical Treatment (QACAM). Both medical students and psychology students were sceptical about the diagnostic and the therapeutic proficiency of doctors and practitioners of CAM. Students' attitudes towards CAM correlated neither with their experiences as CAM patients nor with their emotional and physical condition. It can be assumed that German medical and psychology students will be reluctant to use or recommend CAM in their professional careers. Further studies should examine more closely the correlation between attitudes towards CAM and the students' worldview as well as their existing knowledge of the effectiveness of CAM.     

Suffering and wisdom

Suffering is frequent in life, often ensuing when a wished-for state cannot be realized. One common response to suffering is mourning. Mourning may take problematic forms, and this can lead to chronic denial or embitterment or despair or stagnation. On the other hand, mourning may occur in such manner as to facilitate meaning in life, empathy, caring, and perspective. One's myths and beliefs often affect the mourning process and may themselves be influenced by that process. Different myths accompany or influence different identity patterns and life-styles. The core concepts of religion are often associated with certain myths and beliefs that may inspire meaning and courage, caring and wisdom.The preparation of this paper was supported in part by the Bureau of Community Health Services' Maternal and Child Health Project Grant No. 916 and National Institutes of Child Health and Human Development Grant No. 03110.     

Different is good: connectionism and dynamic systems theory are complementary emergentist approaches to development

Connectionist and dynamic systems approaches to development are similar in that they are both emergentist theories that take a very different perspective from more traditional symbolic systems. Moreover, they are both based on similar mathematical principles. Nevertheless, connectionism and dynamic systems differ in the approach they take to the study of development. We argue that differences between connectionist and dynamic systems approaches in terms of the basic components of the models, what they see as the object of study, how they view the nature of knowledge and their notions of developmental change mean that they each stand to make different and unique contributions to a more complete theory of development. We present an example from our work on how children learn to learn words that illustrates the complementary nature of connectionist and dynamic systems theories.     

Counselling and psychotherapy,complementary and alternative medicine and the future of healthcare

The counselling and psychotherapy profession is undergoing considerable change as a result of government intervention in the form of regulation, funding and efficacy research. In this paper we argue that these changes, even though they challenge some of the basic ways of thinking which have come to underpin the profession since its inception, also offer an opportunity to stimulate debate and thought in regard to how the profession might contribute to the development of healthcare systems in the future. We argue that this could be enhanced if therapists can learn from the experience of practitioners in the field of complementary and alternative medicine (CAM), which has been experiencing similar changes in recent years. Indeed, both fields of clinical activity adopt many similar underlying clinical principles and, according to Samuels (2001), have similar political outlooks. With reference to anthroposophic psychotherapy which, as well as being a form of psychotherapy, is also part of a ‘whole systems’ approach to CAM, we will examine those characteristics of psychotherapy and CAM that can inform the thinking of healthcare systems as a whole.     

Clinical interpretation: The hermeneutics of medicine

I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts. The literary critic reading a novel, the judge asked to apply a law, must arrive at a coherent reading of their respective texts. Similarly, the physician interprets the text of the ill person: clinical signs and symptoms are read to ferret out their meaning, the underlying disease. However, I suggest that the hermeneutics of medicine is rendered uniquely complex by its wide variety of textual forms. I discuss four in turn: the experiential text of illness as lived out by the patient; the narrative text constituted during history-taking; the physical text of the patient's body as objectively examined; the instrumental text constructed by diagnostic technologies. I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutic self-understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject — the living, experiencing patient.     

Dialectics and practical wisdom

Dialectics is essentially the method or logos in which categories of forms are combined to explain things. Dialectics was developed because reason faces difficulties in grasping the sensible world. Practical wisdom is knowledge about some things or certain person or persons because of its variable objects. But it is not entirely specific or only about a particular thing and without universality in any sense. As one kind of dialectics, it combines various elements to accord with the right logos, similar to the way in which various forms are combined in theory. Therefore practical wisdom as a combination or polymerization of elements can be regarded as another kind of logic, namely practical logic or dialectics. __________ Translated from Zhexue Dongtai 哲学动态 (Philosophical Trends), 2005 (4) by Xie Yongkang     

Prototypes and personal templates: collective wisdom and individual differences

This article concerns individual differences in the associative meaning of psychological concepts. Associative meaning may be assessed with prototype methodology, which yields a list of features of the concept ordered according to their rated importance. Our theory concerns individual differences in a concept's associative meaning: A personal template reveals a person's idiosyncratic associative meaning. It is possible to assess the degree to which a personal template matches the corresponding prototype. The theory distinguishes among three types of concepts. One type, for example, specifies a particular behavior to be predicted, for example, a person who is likely to commit suicide, and features of the prototype would include predictors of suicidal behavior. According to the theory, the most prototypical features are (under specifiable conditions) valid predictors, and people with a strong template-to-prototype match possess more valid knowledge about the concept than do people with a weak template-to-prototype match. Other types of concepts cannot be validated (e.g., those describing subjective experiences). In that case, a strong template-to-prototype match does not reflect a person's degree of valid knowledge. The authors provide three applications of the theory.     

Motivation and dietary self-care in adults with diabetes: are self-efficacy and autonomous self-regulation complementary or competing constructs?

This study examined constructs drawn from social-cognitive theory (A. Bandura, 1986) and self-determination theory (E. L. Deci & R. M. Ryan, 1985, 1991) in relation to dietary self-care and life satisfaction among 638 individuals with diabetes. A motivational model of diabetes dietary self-care was proposed, which postulates direct links between self-efficacy/autonomous self-regulation, and adherence/ life satisfaction. Structural equation modeling showed that both self-efficacy and autonomous self-regulation were associated with adherence (betas = .54 and .21, respectively) and with life satisfaction (betas = .15 and .34, respectively). Constraint analyses confirmed that self-efficacy was significantly more associated with adherence, whereas autonomous self-regulation was significantly more associated with life satisfaction. According to the model, interventions for dietary self-care and life satisfaction should focus on increasing self-efficacy and autonomous self-regulation.