Recognizing Racit Knowledge in Medical Epistemology

Abstract

The evidence-based medicine movement advocates basing all medical decisions on certain types of quantitative research data and has stimulated protracted controversy and debate since its inception. Evidence-based medicine presupposes an inaccurate and deficient view of medical knowledge. Michael Polanyi’s theory of tacit knowledge both explains this deficiency and suggests remedies for it. Polanyi shows how all explicit human knowledge depends on a wealth of tacit knowledge which accrues from experience and is essential for problem solving. Edmund Pellegrino’s classic treatment of clinical judgment is examined, and a Polanyian critique of this position demonstrates that tacit knowledge is necessary for understanding how clinical judgment and medical decisions involve persons. An adequate medical epistemology requires much more qualitative research relevant to the clinical encounter and medical decision making than is currently being done. This research is necessary for preventing an uncritical application of evidence-based medicine by health care managers that erodes good clinical practice. Polanyi’s epistemology shows the need for this work and provides the structural core for building an adequate and robust medical epistemology that moves beyond evidence-based medicine.

Notes

• 1 Gordon Guyatt and Drummond Rennie, eds., Users’ Guides to the Medical Literature: A Manual for Evidence-based Clinical Practice (Chicago: AMA Press, 2002); David L. Sackett et al., Evidence-based Medicine: How to Practice and Teach EBM, 2nd ed. (New York: Churchill Livingstone, 2000). These texts are written by the people who invented EBM and are the basis for the conception of EBM discussed in this article. For a detailed examination of the movement’s historical development see Jeanne Daly, Evidence-based Medicine and the Search for a Science of Clinical Care (Berkeley: University of California Press and New York: Milbank Memorial Fund, 2005).

• 2 See Aaron M. Cohen, P. Zoë Stavri, and William R. Hersh, “A Categorization and Analysis of the Criticisms of Evidence-based Medicine,” International Journal of Medical Informatics 73 (2004): 35–43 and R. Brian Haynes, “What Kind of Evidence Is It that Evidence-based Medicine Advocates Want Health Care Providers and Consumers to Pay Attention To?” Biomed Central Health Services Research 2 (2002): 3.

• 3 Cohen, Stavri, and Hersh, “A Categorization and Analysis of the Criticisms of Evidence-based Medicine,” cited in n. 2, above, pp. 35–43.

• 4 Nikola Biller-Andorno, C. Lenk, and J. Leititis, “Ethics, EBM, and Hospital Management,” Journal of Medical Ethics 30 (2004): 136–140; Donna Dickenson and Paolo Vineis, “Evidence-based Medicine and Quality of Care,” Health Care Analysis 10 (2002): 243–259; Alvan R. Feinstein and Ralph I. Horwitz, “Problems in the ‘Evidence’ of ‘Evidence-based Medicine,”’ American Journal of Medicine 103 (1997): 529–535.

• 5 Nikola Biller-Andorno, Reidar K. Lie, and Ruud ter Meulen, “Evidence-based Medicine as an Instrument for Rational Health Policy,” Health Care Analysis 10 (2002): 261–275; S. I. Saarni and H. A. Gylling, “Evidence-based Medicine Guidelines: A Solution to Rationing or Politics Disguised as Science?” Journal of Medical Ethics 30 (2004): 171–175.

• 6 Many individual physicians may embrace a weaker, less controversial version of EBM that involves merely incorporating insights from clinical epidemiology into their practice. Managers and administrators, however, are inclined to accept EBM’s claim to be the new medical paradigm and so may attempt to minimize physicians’ use of non-statistical or “non-evidence-based” information. EBM threatens good medical practice not because it merely fails to recognize that tacit knowledge is an essential part of medical knowledge, but because it actively suppresses tacit knowledge as unreliable and biased.

• 7 Guyatt and Rennie, Users’ Guides to the Medical Literature: A Manual for Evidence-based Clinical Practice, cited in n. 1, above, p. 217.

• 8 Haynes, “What Kind of Evidence Is It that Evidence-based Medicine Advocates Want Health Care Providers and Consumers to Pay Attention To?” cited in n. 2, above, p.3.

• 9 One of EBM’s central goals is the development of explicit, universal rules for reading journal articles, evaluating research results, and applying these results to medical practice. These rules are meant to foster systematic, bias-free medical practice, but criticism of every proposed set of rules has shown them to be insufficient as reliable guides to medical practice. EBM proponents have been forced to create secondary rules for interpreting their primary rules or, more commonly, to invoke nebulous, non-systematic concepts that somehow pertain in uncertain situations (see n. 7 and n. 8, above). EBM’s failure is not a result of insufficient effort or clarity, but reflects a fundamental epistemological deficiency that stems from the mistaken belief that all real knowledge must be wholly explicit and formalizable.

• 10 i.e. epistemologies that define knowledge as justified true belief. See Peter D. Klein, “Epistemology,” in Routledge Encyclopedia of Philosophy, vol. 3, ed. Edward Craig (New York: Routledge, 1998), 362–365.

• 11 Michael Polanyi, Personal Knowledge (London: Routledge & Kegan Paul, 1962; reprint, London: Routledge, 1998). Except where other works are cited, my account of Polanyi’s thought is drawn from this book, which is Polanyi’s magnum opus.

• 12 Polanyi uses several different terms to describe various aspects of this distinction. For simplicity I have used only tacit and explicit in this paper, but I do not believe this simplification significantly alters or vitiates the substance of Polanyi’s ideas.

• 13 Peter N. Burns, “Interpretation and Analysis of Doppler Signals,” in Clinical Applications of Doppler Ultrasound, 2nd ed., eds. Kenneth J. W. Taylor, Peter N. Burns, and Peter N. T. Wells (New York: Raven Press, 1995), 55–98, on p. 62.

• 14 Polanyi, Personal Knowledge, cited in n. 11, above, p. 101.

• 15 Tacit knowledge ranges from conscious knowledge of tools to unconscious awareness of our bodies. Polanyi sometimes suggests that tacit knowledge extends even to our bodies’ inner workings. See Polanyi, Personal Knowledge, cited in n. 11, above, pp. 58–62 and Michael Polanyi and Harry Prosch, Meaning (Chicago: University of Chicago Press, 1975), p. 39. Marjorie Grene develops this point further on p. 170 of her article, “Tacit Knowing: Grounds for a Revolution in Philosophy,” Journal of the British Society for Phenomenology 8 (1977): 164–171.

• 16 Michael Polanyi, The Tacit Dimension (Garden City, New York: Doubleday & Company, 1966), pp. 3–4.

• 17 Michael Polanyi, “Creative Imagination,” in Michael Polanyi, Society, Economics, and Philosophy: Selected Papers, ed. R. T. Allen (New Brunswick, New Jersey: Transaction Publishers, 1997), 249–266 on pp. 257–258.

• 18 Polanyi, Personal Knowledge, cited in n. 11, above, p. 309. For further distinction between the personal and the subjective see Polanyi, cited in n. 11, above, pp. 300–303.

• 19 Donald W. Seldin, “The Medical Model: Biomedical Science as the Basis of Medicine,” in Beyond Tomorrow: Trends and Prospects in Medical Science (New York: The Rockefeller University, 1977), 31–40.

• 20 Abraham Flexner, Medical Education in the United States and Canada (New York City: The Carnegie Foundation for the Advancement of Teaching, 1910), p. 25.

• 21 Seymour S. Kety, “From Rationalism to Reason,” The American Journal of Psychiatry 131 (1974): 957–963; Paul E. Meehl, “Specific Etiology and Other Forms of Strong Influence: Some Quantitative Meanings,” Journal of Medicine and Philosophy 2 (1977): 33–53.

• 22 Gerd Gigerenzer et al., The Empire of Chance: How Probability Changed Science and Everyday Life (Cambridge: Cambridge University Press, 1989), pp. 46–47.

• 23 Seldin, “The Medical Model: Biomedical Science as the Basis of Medicine,” cited in n. 19, above, p. 40.

• 24 e.g. Kety, “From Rationalism to Reason,”cited in n. 21, above.

• 25 e.g. G. Gayle Stephens, “Reflections of a Post-Flexnerian Physician,” in The Task of Medicine, ed. Kerr L. White (Menlo Park, California: The Henry J. Kaiser Family Foundation, 1988): 172–189 and Kirsti Malterud, “The Legitimacy of Clinical Knowledge: Towards a Medical Epistemology Embracing the Art of Medicine,” Theoretical Medicine 16 (1995): 183–198.

• 26 George L. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science 196 (1977): 129–136.

• 27 e.g. K. Danner Clouser, “Clinical Medicine as Science: Editorial,” Journal of Medicine and Philosophy 2 (1977): 1–7; Lee A. Forstrom, “The Scientific Autonomy of Clinical Medicine,” Journal of Medicine and Philosophy 2 (1977): 8–19; Meehl, “Specific Etiology and Other Forms of Strong Influence: Some Quantitative Meanings,” cited in n. 21, above.

• 28 Alvan R. Feinstein, Clinical Epidemiology: The Architecture of Clinical Research (Philadelphia: W. B. Saunders Company, 1985); Robert H. Fletcher, Suzanne W. Fletcher, and Edward H. Wagner, Clinical Epidemiology: The Essentials (Baltimore: Williams and Wilkins, 1982); David L. Sackett, R. Brian Haynes, and Peter Tugwell, Clinical Epidemiology: A Basic Science for Clinical Medicine (Boston: Little, Brown, and Company, 1985).

• 29 Proponents of EBM call it a “new paradigm” for medicine. See The Evidence-based Medicine Working Group, “Evidence-based Medicine: A New Approach to Teaching the Practice of Medicine.” Journal of the American Medical Association 268 (1992): 2420–2425 and Guyatt and Rennie, Users’ Guides to the Medical Literature: A Manual for Evidence-based Clinical Practice, cited in n. 1, above , p. 4.

• 30 Haynes, “What Kind of Evidence Is It that Evidence-based Medicine Advocates Want Health Care Providers and Consumers to Pay Attention To?” cited in n. 2, above.

• 31 Edmund D. Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” in Clinical Judgment: A Critical Appraisal, eds. H. T. Engelhardt, Jr, S. F. Spicker, and B. Towers, Philosophy and Medicine, vol. 6 (Boston: D. Reidel Publishing Company, 1979), 169–194.

• 32 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, pp. 171–172; cf. Edmund D. Pellegrino and David C. Thomasma, A Philosophical Basis for Medical Practice (New York: Oxford University Press, 1981), pp. 73–77.

• 33 Edmund D. Pellegrino, “The Healing Relationship: The Architectonics of Clinical Medicine,” in The Clinical Encounter, ed. Earl E. Shelp, Philosophy and Medicine, vol. 14 (Boston: D. Reidel Publishing Company, 1983), 153–172, on p. 163.

• 34 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, pp. 173, 190–191; Edmund D. Pellegrino and David C. Thomasma, The Virtues in Medical Practice (New York: Oxford University Press, 1993), pp. 84–91.

• 35 Pellegrino, “The Healing Relationship: The Architectonics of Clinical Medicine,” cited in n. 33, above, p. 162. Pellegrino admits that even his theory cannot be wholly sufficient. It might not be applicable, for example, to physicians who do not interact with live patients such as radiologists and pathologists.

• 36 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 176.

• 37 Others have reached this conclusion independently, e.g. Eric J. Cassell, Talking with Patients, vol. 1 (Cambridge: The MIT Press, 1985), p. 134; Stephens, “Reflections of a Post-Flexnerian Physician,” cited in n. 25, above, p. 177.

• 38 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 177 and p. 172, respectively.

• 39 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 181.

• 40 Pellegrino, “The Healing Relationship: The Architectonics of Clinical Medicine,” cited in n. 33, above, p. 162.

• 41 Pellegrino, “The Healing Relationship: The Architectonics of Clinical Medicine,” cited in n. 33, above, p. 164.

• 42 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 187.

• 43 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 191.

• 44 Pellegrino, “The Healing Relationship: The Architectonics of Clinical Medicine,” cited in n. 33, above, p. 163.

• 45 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 188.

• 46 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 187.

• 47 Grene, “Tacit Knowing: Grounds for a Revolution in Philosophy,” cited in n. 15, above, p. 165. Polanyi’s use of the phrase “tacit knowing” supports Grene’s interpretation. His writings rarely if ever contain the phrase “tacit knowledge,” though it is commonly attributed to him.

• 48 Polanyi and Prosch, Meaning, cited in n. 15, above, pp. 34–42.

• 49 Pellegrino and Thomasma, The Virtues in Medical Practice, cited in n. 34, above, p. 90.

• 50 e.g. Pellegrino and Thomasma, The Virtues in Medical Practice, cited in n. 34, above, pp. 87–89.

• 51 Michael Polanyi, “On the Modern Mind,” in Michael Polanyi, Scientific Thought and Social Reality, ed. F. Schwartz, Psychological Issues, vol. 8, no. 4 (New York: International Universities Press, 1974), 131–149, on p. 139.

• 52 Polanyi (Personal Knowledge, cited in n. 11, above, pp. 69–131) demonstrates that even spoken communication entails a complex set of assumptions about meaning and mental models that rest somehow on inarticulable bodily processes. Meaningful communication thus requires some assumptions about reality; the important point is that the physician must work to engage the patient as a person and not as a reified disease or stock character (i.e. he must not focus on a patient as just another instance of the middle-aged-obese-woman-with-poor-psychological-coping-skills-who-needs-a-cholecystectomy stereotype but rather as an individual who happens to have these characteristics) so that he can remain open both to tacit communication and compassion and to the medical particulars of each patient’s case.

• 53 Michael Polanyi, “Faith and Reason,” in Michael Polanyi, Scientific Thought and Social Reality, ed. F. Schwartz, Psychological Issues, vol. 8, no. 4 (New York: International Universities Press, 1974), 116–130, on p. 123.

• 54 The medical model and evidence-based medicine do discuss hypothesis formation briefly but in so doing appeal to the “special illumination peculiar to clinicians” of which Pellegrino (cited in n. 31, above, p. 187) is rightly suspicious. Popper, whose hypothetico-deductive framework underpins the medical model, saw hypothesis generation as a kind of Bergsonian creative intuition. See Karl Popper, The Logic of Scientific Discovery (New York: Basic Books, 1959; reprint, London: Routledge Classics, 2002), p. 8. The standard EBM text, on the other hand, states that formulation of a differential diagnosis “happens largely at an unconscious level.” (Guyatt and Rennie, cited in n. 1, above, p. 103).

• 55 Malterud, “The Legitimacy of Clinical Knowledge: Towards a Medical Epistemology Embracing the Art of Medicine,” cited in n. 25, above; Stephens, “Reflections of a Post-Flexnerian Physician,” cited in n. 25, above.

• 56 In hospitals this information is available in patients’ charts and messages from other hospital staff. In clinics it comes from nursing assessments or, if the physician has treated the patient before, from prior experience.

• 57 Gilbert M. Goldman, “The Tacit Dimension of Clinical Judgment,” Yale Journal of Biology and Medicine 63 (1990): 47–61.

• 58 Kathryn Montgomery Hunter, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991), p. 101.

• 59 David M. Eddy and Charles H. Clanton, “The Art of Diagnosis: Solving the Clinicopathological Exercise,” in Professional Judgment: A Reader in Clinical Decision Making, eds. Jack Dowie and Arthur Elstein (New York: Cambridge University Press, 1988): 200–211.

• 60 Peter B. Medawar, “Is the Scientific Paper Fraudulent?” Saturday Review 47 (1964): 42–43.

• 61 Polanyi, Personal Knowledge, cited in n. 11, above, p. 205.

• 62 Pellegrino and Thomasma, The Virtues in Medical Practice, cited in n. 34, above, pp. 84–91.

• 63 Aristotle, Nichomachean Ethics, trans. Terence Irwin (Indianapolis: Hackett Publishing Company, 1985), Book VI, 1140b8–10, 1141b14–22.

• 64 Pellegrino, “The Anatomy of Clinical Judgments: Some Notes on Right Reason and Right Action,” cited in n. 31, above, p. 173. When this paper was substantially complete I discovered that Hillel Braude had independently developed a related but more detailed critique of Pellegrino’s concept of phronesis as part of his unpublished Ph.D. dissertation, “The Invisible Thread: Intuition in Medical and Moral Reasoning” (University of Chicago, 2006). I am grateful for the insights and exchange of information that have resulted from our correspondence.

• 65 Samuel Gorovitz and Alasdair MacIntrye, “Towards a Theory of Medical Fallibility,” Journal of Medicine and Philosophy 1 (1976): 51–71.

• 66 e.g. Alvan R. Feinstein, “‘Clinical Judgment’ Revisited: The Distraction of Quantitative Models,” Annals of Internal Medicine 120 (1994): 799–805; Michael Scriven, “Clinical Judgment,” in Clinical Judgment: A Critical Appraisal, eds. H. T. Engelhardt, S. F. Spicker, and B. Towers. Philosophy and Medicine, vol. 6 (Boston: D. Reidel Publishing Company, 1979), 3–16; Howard F. Stein, “The Role of Some Nonbiomedical Parameters in Clinical Decision Making: An Ethnographic Approach,” Qualitative Health Research 1 (1991): 6–26.

• 67 Kirsti Malterud, “The Art and Science of Clinical Knowledge: Evidence beyond Measures and Numbers,” Lancet 358 (2001): 397–400.

• 68 John Gabbay and Andrée le May, “Evidence-based Guidelines or Collectively Constructed ‘Mindlines’?” British Medical Journal 329 (2004): 1013–1016.

• 69 Carl Thompson et al., “Research Information in Nurses’ Clinical Decision Making: What Is Useful?” Journal of Advanced Nursing 36 (2001): 376–388.

• 70 e.g. Benjamin F. Crabtree, William L. Miller, and Kurt C. Strange, “Understanding Practice from the Ground Up,” Journal of Family Practice 50 (2001): 881–887.

• 71 Cecil G. Helman, Culture, Health, and Illness, 4th ed. (London: Arnold, 2001); James P. Spradley, The Ethnographic Interview, (New York: Holt, Rhinehart, and Winston, 1979).

• 72 e.g. Mike Cranney et al., “Why Do GPs Not Implement Evidence-based Guidelines? A Descriptive Study,” Family Practice 18 (2001): 359–363; Michael L. Green and Tanya R. Ruff, “Why Do Residents Fail to Answer Their Clinical Questions? A Qualitative Study of Barriers to Practicing Evidence-based Medicine,” Academic Medicine 80 (2005): 176–182; Stephen Harrison et al., “General Practitioners’ Uptake of Clinical Practice Guidelines: A Qualitative Study,” Journal of Health Services Research and Policy 8 (2003): 149–153; Kamlesh Khunti et al., “Heart Failure in Primary Care: Qualitative Study of Current Management and Perceived Obstacles to Evidence-based Diagnosis and Management by General Practitioners,” European Journal of Heart Failure 4 (2002): 771–777.

• 73 For a discussion and application of Dreyfus’ theories (which he developed from Heidegger’s philosophy) to medical practice see Eran Patrick Klein, “Towards a Skills-based Philosophy of Medicine” (Ph.D. diss., Georgetown University, 2002), pp. 122–160.

• 74 Eric J. Cassell, The Nature of Suffering and the Goals of Medicine (New York: Oxford University Press, 1991), pp. 218–219.

• 75 Carl Bereiter and Marlene Scardamalia, Surpassing Ourselves: An Inquiry into the Nature and Implications of Expertise (Chicago: Open Court Press, 1993), pp. 43–75.

• 76 See n. 6, above.

• 77 cf. Goldman, “The Tacit Dimension of Clinical Judgment,” cited in n. 57, above, pp. 58–59.

• 78 Richard Gelwick, “Michael Polanyi and the Philosophy of Medicine,” Tradition and Discovery 18, no. 3 (1992): 21–29; Stefania Jha proposes a “neo-Polanyian medical epistemology” that is confusing and relies heavily on Polanyi’s ill-defined and controversial concept of “from-at” knowing, but she correctly recognizes that Polanyi’s epistemology provides the tools that make possible an adequate understanding of the clinical encounter. See “The Tacit-Explicit Connection” in her book Reconsidering Michael Polanyi’s Philosophy (Pittsburgh: University of Pittsburgh Press, 2002), 189–203.

• 79 e.g. Maurice Merleau-Ponty and Alfred Schutz.

• 80 e.g. Cassell, cited in n. 37 and n. 74, above.

• 81 e.g. Max Scheler, The Nature of Sympathy, trans. Peter Heath (Hamden, Connecticut: Archon Books, 1970).