Evidence and expertise.
This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence-based practice. Two related arguments are considered. The first suggests that standard accounts of evidence-based practice imply an overly narrow view of 'evidence', and that a more inclusive concept, incorporating 'patterns of knowing' not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non-problematically to individual patients in specific contexts, and points out that this is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the 'patterns of knowing', referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence-based practice as a template for health-care.
Paley
John
J
Department of Nursing and Midwifery, University of Stirling, Stirling, UK. j.h.paley@stir.ac.uk
D000704:Analysis of Variance; D015982:Bias; D002983:Clinical Competence / Q000592:standards*; D003627:Data Interpretation, Statistical; D003657:Decision Making; D019317:Evidence-Based Medicine / Q000458:organization & administration*; D006694:Holistic Health; D006801:Humans; D007206:Individuality; D019545:Intuition; D007600:Judgment; D019359:Knowledge; D009736:Nursing Process / Q000458:organization & administration*; D015399:Nursing Research / Q000458:organization & administration*; D018802:Patient-Centered Care / Q000458:organization & administration; D010687:Philosophy, Nursing; D015203:Reproducibility of Results; D035501:Uncertainty