Medicine and books: Developing Professional Judgement in Health Care
Authors: Richard L Cruess
Journal: BMJ (1998)

Della Fish, Colin Coles 

Heinemann, £17.99, pp 318 

ISBN 0 7506 3123 6 

Many people believe that the accomplishments of modern science have tilted the balance of health care away from art towards science. Attempts have been made to redress this by defining practice in other than scientific terms and by proposing actions to promote the art of medicine. 

Some of the most successful attempts have been those of Schon (The Reflective Practitioner, 1983; Educating the Reflective Practitioner, 1987). Building on Schon’s work, these authors focus on the art of medicine, almost denying any role for science. 

They contend that professional practice can be characterised in terms of artistry and believe that, by carefully examining events drawn from various practices, they can illuminate the principles on which the art of practice is based. They analyse theories of practice in detail, presenting readers with literature that is usually unavailable to most healthcare professionals. The core of the book consists of descriptions of incidents drawn from the daily practice of individuals in nursing, physical and occupational therapy, healthcare education, and medicine. Each incident is analysed and commented on by the practitioner with the object of providing better self understanding. This exercise is entitled “insider practitioner research.” 

The book is interesting, well written, and provocative. Unfortunately, the case studies do not shed light on the art of practice. While they are undoubtedly of value to the practitioners, each case remains unique, contributing little to our further understanding of the art of medicine. This arises partly from the extreme difficulty of defining the art in practice. The insider practitioner research does not seem incorporated into a unified body of knowledge that assists in the abstract definition of the subject. 

The authors propose that insider practitioner research should be established as a means of improving the practice of medicine and apparently believe that this will help discharge the difficulties encountered in meeting the justifiable request from society for “accountability.” They state that much healthcare practice has “tangible but immeasurable consequences” and believe that an alternate definition of accountability would satisfy society. A professional would be expected to voluntarily “give an account of their practice” that would allow the complexities of practice to be taken into consideration. While the idea is interesting, the terms and conditions under which accountability is to be given are, in fact, set by society and not by the professionals, and it is unlikely that the new definition will be acceptable to a society increasingly interested in results. 

To heal and to care has always required more than scientific expertise and technical skill. It requires a rich understanding of human nature, an idealistic engagement with values, and an exposure to the broad panorama of the social sciences and humanities. Insider practitioner research offers no assurance that this will take place. 

Finally, the lack of recognition of the place of science in modern health care is disturbing. All evidence indicates that society, while wishing for caring and compassionate healers skilled in the art of medicine, wants practice to be based on sound scientific principles. If professionals do not respond to societal demands in a balanced way, the difficulties being experienced by the professions will not be alleviated.