Clinical Judgement in the Health and Welfare Professions Extending the evidence base • How do clinicians use formal knowledge in their practice? • What other kinds of reasoning are used? • What is the place of moral judgement in clinical practice? In the last decade, the problem of clinical judgement has been reduced to the simple question of what works? However, before clinicians can begin to think about what works, they must first address more fundamental questions such as: what is wrong, and what sort of problem is it? The complex ways in which professionals negotiate the process of case formulation remain radically under-explored in the existing literature. This timely book examines this neglected area. Drawing on the authors’ own detailed ethnographic and discourse analytic studies and on developments in social science, the book aims to reconstitute clinical judgement and case formulation as both practical- moral and rational-technical activities. By making social scientific work more accessible and meaningful to professionals in practice, it develops the case for a more realistic approach to the many reasoning processes involved in clinical judgement. Clinical Judgement in the Health and Welfare Professions has been written for educators, managers, practitioners and advanced students in health and social care. It will also appeal to those with an interest in the analysis of institutional discourse and ethnographic research. Susan White is Professor of Health and Social Care at the University of Huddersfield. She is interested in the social and moral dimensions of professional practice and has completed discourse analytic and ethnographic studies in a range of health and welfare settings. John Stancombe is a full time consultant clinical psychologist in the NHS with over twenty years experience of practice. He currently works in the Child Psychological Service of the Trafford Healthcare NHS Trust in Manchester. 9 780335 208746 ISBN 0-335-20874-6 Cover design: Barker/Hilsdon www.openup.co.uk Clinical Judgement in the Health and Welfare Professions Extending the evidence base Clinical Judgement in the Health and Welfare Professions Susan White and John Stancombe Susan White and John Stancombe Susan White and John Stancombe Clinical judgement…professions 27/3/03 3:05 PM Page 1 Clinical Judgement in the Health and Welfare Professions Extending the evidence base Clinical Judgement in the Health and Welfare Professions Extending the evidence base Susan White and John Stancombe Open University Press Maidenhead · Philadelphia Open University Press McGraw-Hill Education McGraw-Hill House Shoppenhangers Road Maidenhead Berkshire England SL6 2QL email: enquiries@openup.co.uk world wide web: www.openup.co.uk and 325 Chestnut Street Philadelphia, PA 19106, USA First Published 2003 Copyright © White & Stancombe 2003 All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher or a licence from the Copyright Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of 90 Tottenham Court Road, London, W1P 0LP. A catalogue record of this book is available from the British Library ISBN 0 335 20874 6 (pb) 0 335 20875 4 (hb) Library of Congress Cataloging-in-Publication Data White, Susan, 1961– Clinical judgement in the health and welfare professions: extending the evidence base/Susan White and John Stancombe. p. cm. Includes bibliographical references and index. ISBN 0–335–20875–4 (hbk.) – ISBN 0–335–20874–6 (pbk.) 1. Medical logic. 2. Evidence-based medicine. I. Stancombe, John, 1957–II. Title. R723. W465 2003 616–dc21 2002035545 Typeset by RefineCatch Limited, Bungay, Suffolk Printed in Great Britain by Biddles Ltd, www.biddles.co.uk Contents Preface viii Acknowledgements xii PART 1 Theorizing Clinical Judgement 1 1 Science and art 3 Approaches to understanding clinical judgement Practically Popper? The clinician as everyday scientist 5 The practical problems with Popper 6 Tackling error: the clinician and cognitive (in)competence 8 The relationship between the knower and the known 14 The artfulness of science and the science of artfulness 16 Summary 22 2 Seductive certainties 24 The ‘scientific-bureaucratic’ model Political pragmatism: the ascent of scientific-bureaucratic rationality 26 What is wrong with evidence-based practice? 28 The Enlightenment: reason, progress and science 33 Shaking the certainty 34 Clinical judgement and different kinds 37 Summary 39 3 Interrogating the tacit dimension 40 Concepts and methods The humanities and humaneness 41 Psychoanalysis and self-knowledge 42 Interpretive social science and the sociology of everyday life 44 Deep familiarity: the ethnographic case study 49 Ordinary action: ethnomethodology and conversation analysis 51 Membership categorization: talking morality 55 Storytelling in clinical practice: discourse studies 58 Summary 60 PART 2 Being Realistic about Clinical Judgement: Case Formulation in Context 61 4 Clinical science as social practice 63 Using formal knowledge in professional work From laboratory to clinic: producing and distributing science 64 Looking and learning? Observation in practice 68 Reading and interpreting the body: journal science in action? 69 Beyond ‘knowledge to go?’ Popular knowledge and clinical practice 78 Reading relationships: psychological theory and observation 80 Summary 90 5 Emotion and morality 91 Blameworthiness, creditworthiness and clinical judgement Good patients/bad patients 93 Moral judgements and organizational context 95 Moral judgements and child health: invoking parental love 98 Privileging the child’s voice: negotiating blame in interaction 102 Producing moral selves: getting the job done 108 Contesting moral selves: blame and moral judgement in multidisciplinary work 110 Summary 112 6 Science, morality and case formulation in paediatrics 114 A case study The problematics of case formulation in paediatrics 114 The natural and the social: ‘not just medical’ cases 116 Summary 128 7 Managing multiple versions 130 Rhetoric and moral judgement in a family therapy case The moral context of family work 131 Doing neutrality in talk with families: the first paradox 133 Making knowledge and performing clinical judgement: the second paradox 136 Moving from backstage to frontstage: the third paradox 138 Summary 143 8 Clinical judgement in context 145 Towards a more realistic realism Misunderstanding science: why we don’t need the ‘science wars’ 148 Can EBP provide protection from fashion and fad? 151 vi CONTENTS Sociological inquiry: some uses and abuses 153 Connecting research with the swampy lowlands of practice 155 Developing reflexivity: beyond reflection on action 156 Beyond training: educating judgement 159 Appendix: Transcription conventions 163 Glossary 164 Recommended further reading 169 References 174 Index 187 CONTENTS vii Preface This book examines how professionals practising in various health and welfare settings go about the ordinary, but complicated, business of making sense of the symptoms and troubles with which their patients or clients present. Our motivations for writing the book are varied, but are the result of our conversations with each other about the problem of judgement in clinical practice, which have taken place over many years of professional, academic and research collaboration. We share a practice background in child health and welfare services, but also an academic interest in the importance of language and social interaction in human life. There is a complex dialogue, and at times an inevitable tension, between the conceptual frameworks derived from the study of everyday talk and work and the pragmatic day- to-day business of getting clinical work done. Our experience of these dialogues and tensions has inspired us to convince others that the under- standings that result may help them to think about their work in new and interesting ways. This recasting of practice is particularly important in the current policy climate. In the past decade, the problem of clinical judgement has become reduced to the simple question ‘What works?’ Codified knowledge in various forms has come to be defined as a safe and secure base for professional judge- ments. Such knowledge is ostensibly insulated from and uncontaminated by the contingencies and errors of everyday practice. While we certainly do not wish to suggest that the efficacy and safety of treatments and interventions is in any way unimportant, it does lead to a conspicuous neglect of other areas of clinical activity. Before they can begin to think about ‘What works?’ clinicians must first address the question ‘What’s wrong?’, or ‘What sort of problem is this?’ Yet the complex processes by which professionals negotiate problem formulation remain seriously under-explored in current policy initiatives. Drawing on detailed empirical studies of everyday practice and develop- ments in the social studies of science, we aim to convince you that clinical judgement and case formulation have important social and moral dimensions. We are not suggesting that science and evidence are not important. Such an argument would be ridiculous and quite untenable. Instead, we want to explore how science and evidence are used in practice. For example, how do clinicians interpret X-rays and test results? How do understandings of disease change over time and what kinds of things influence those processes? Is the science involved in clinical work different in any way from that taking place in laboratories? Is theoretical knowledge different from scientific knowledge? If so, what does this mean for practice? Moreover, while recognizing the importance of science, we want to exam- ine the role of other forms of reasoning, particularly that of emotion and moral judgement. For example, our work in child health and welfare services has alerted us to the importance of blame and responsibility. Our clinical experience is that accountability is a ubiquitous but frequently under-explored and tacit theme in everyday work with children and families. For example, the question of blame is often explicit right from the beginning of work with families. Parents may blame themselves or their partner for their child’s ‘prob- lem’; or a young person may blame their parent for the family’s troubles. Alternatively, parents may present overt accounts or explanations of their child’s problem that attribute blame or responsibility to factors beyond their control. For example, a parent might attribute the problem to individual fac- tors in the child such as difficult temperament or individual pathology, or to the inappropriate behaviour of the other parent, or to some factor in school. Thus, for one family trouble there may be many competing causal explan- ations, each carrying varying potential for moral censure of individual family members. However, it is not only in family work that moral judgement is important. We argue that it is a mundane feature of work in a variety of set- tings, including biomedicine. As such, it needs to be properly explored and debated. In essence, this book contends that problems of judgement are intrinsic and inescapable imperatives for clinicians. Professionals are routinely faced with having to decide which diagnosis, or whose version or account of the troubles, they find most convincing and/or morally robust. In exploring these themes we have drawn on our own and others’ empirical work in health and welfare settings. Many studies of professional practice are oriented to uncover- ing errors or abusive practices. That is, they are concerned with how work should be done. Our intention is different. We set out to describe how it is done in a variety of settings. Therefore, the studies we have drawn upon all take a descriptive approach. They seek to describe in detail the ordinary work taking place in clinics and services, rather as an anthropologist may describe the everyday practices and understandings of faraway cultures. Many of the stud- ies make use of recordings of conversations to illustrate the way work gets done in interaction and how understandings emerge over time. While there is an abundant literature on professional–client interaction in various settings, we have concentrated primarily on studies of interprofessional communication. We have done so because our concern is with how profes- sionals formulate cases. Case formulations often remain unarticulated in encounters with patients and clients and may not exist as single events pro- duced spontaneously on discrete occasions. They may, for example, emerge gradually over time or through conversations with colleagues. They may thus PREFACE ix [...]... statistical modelling to approaches that stress the importance of intuition, tacit knowledge, language use and practical wisdom in clinical judgement We discuss all these approaches in due course, but begin by looking at attempts to reduce the uncertainty and the potential for human failure inherent in judgement- making Again, the field is dominated by analyses of clinical reasoning in biomedicine and professions. .. understandings; the role of ‘intuition’ or ‘practical wisdom’ in clinical judgement; the importance of language, particularly storytelling and persuasion, in clinical judgement 16 THEORIZING CLINICAL JUDGEMENT The artfulness of science and the science of artfulness On occasions when clinicians are in full possession of the necessary information, the hard scientific facts, they still must allow for their... problem-solving tasks involving both limited stimuli and limited choice There is no such control in clinical encounters, where the clinician and client frequently confront each other as ‘moving targets’ struggling to comprehend each other’s intentions (Cicourel 1999) In complex settings, the clinician’s brain may just be much cleverer than the computer The relationship between the knower and the known The. .. hypothetico-deductive strategy remains central to analyses of clinical judgement, it has increasingly been criticized on the grounds that it gives an incomplete understanding of the processes involved, and because it underestimates both certainty and uncertainty in day-to-day decision-making It has been challenged and supplemented by other ways of thinking about and attempting to improve judgement- making These range from... by the Economic and Social Research Council (research grant number R000222892) PART 1 Theorizing Clinical Judgement 1 Science and art Approaches to understanding clinical judgement Clinicians are determinists in their diagnostic activities That is, symptoms, signs and the like are viewed as manifestations of underlying causal processes that can be known in principle Because much clinical reasoning involves... collecting and interpreting evidence (statistics), dealing with uncertainty (probability theory), synthesizing evidence and estimating outcomes (mathematics) and making decisions (economics and decision theory) These languages are not currently learned by most clinical policy makers; they should be (Eddy 1988: 58) Often making use of statistics, probability theory and quantitative outcome measures, these... facilitates the examination of clinical judgement in context and allows a proper 4 THEORIZING CLINICAL JUDGEMENT acknowledgement of its complexity In Chapter 3, we say more about why we think this particular approach and the understandings it can yield are important for practitioners However, first we need to summarize the existing literature on clinical judgement and raise some questions about the sorts... embedded in the action-present It is contained in the action at a point where it will 18 THEORIZING CLINICAL JUDGEMENT make a difference Schön’s work has been very in uential in those occupations operating in the ‘swampy lowlands’, such as therapy, social work and nursing For example, Benner and her colleagues (Benner 1987; Benner et al 1996) have undertaken a number of studies examining nurses’ clinical. .. investigators probing the workings of the physician’s mind, and they phrased their descriptions of medical practice in the same way.’ Probability and clinical judgement: Bayes’ theorem and decision analysis We have already underscored the probabilistic nature of clinical judgement across a range of settings An assortment of models has been created to assist clinicians with the calculation of probabilities and also... has limitations in dealing with ambiguity, complexity and often intractable uncertainty However, there is also some evidence that the hypothetico-deductive method may not be the best way of understanding the processes of clinical judgement in cases which are relatively straightforward and certain For example, during routine clinical encounters involving familiar non-complex cases, experienced practitioners . Judgement in the Health and Welfare Professions Extending the evidence base Clinical Judgement in the Health and Welfare Professions Extending the evidence base Susan. Barker/Hilsdon www.openup.co.uk Clinical Judgement in the Health and Welfare Professions Extending the evidence base Clinical Judgement in the Health and Welfare Professions