The Reflective Practitioner

[zenman]

"In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing 'messes' incapable of technical solution. The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are the problems of greatest human concern. Shall the practitioner stay on the high, hard ground where he can practice rigorously, as he understands rigor, but where he is constrained to deal with problems of relatively little social importance? Or shall he descend to the swamp where he can engage the most important and challenging problems if he is willing to forsake technical rigor?"
- Donald Schon

Thoughts?

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[kugel]

"In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing 'messes' incapable of technical solution. The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are the problems of greatest human concern. Shall the practitioner stay on the high, hard ground where he can practice rigorously, as he understands rigor, but where he is constrained to deal with problems of relatively little social importance? Or shall he descend to the swamp where he can engage the most important and challenging problems if he is willing to forsake technical rigor?"
- Donald Schon

Thoughts?

My response:
"Gimme' some boots, so I can go back into the swamp. I wore out my first 47 pairs."
I'll use the rigorous research (from people I greatly admire) as best I can to provide aid and comfort in the murky swamp that is the life of these patients. The researchers' rigor provides me some structure and guidance so that my efforts are not simply guesses and whim.

 

[dl2dp2]

The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are the problems of greatest human concern.
- Donald Schon

Thoughts?

This main thesis is faulty precisely because it was written by a philosopher--especially of the continental flavor. Modern society cares very little about "swampy questions" which are solved only through non-technical methods like religion, art and meditation. In medicine, the vast majority of questions that have the most meaningful impact in society are studied through careful empirical, rigorous, technical analysis, from Framingham studies to the evidence based psychotherapy modalities. Even in normative fields like ethics and law, the evolving approach involves schools like "law and economics" and quantitative methods. Most of the policy documents anywhere from the federal budget to the supreme court decisions are literally filled with empirical data, expert opinions, literature, statistics, etc...

Any attempts to justify an inability to process quantitative, evidence based literature is no-longer tenable for any professional based on the "trivial to society" argument. In fact, it's easy to argue that non-technical disciplines are more or less "unimportant" to our society, as humanities department's budgets/enrollments are continually being cut--Stanley Fish has written extensively on this subject. From a social welfare perspective, the study of any of the "swampy" disciplines affords relatively value to society. Obviously, a PhD in English Literature has some aesthetic value that is not readily addressed by social welfare, but that's a separate issue.

 

[Indryd]

This main thesis is faulty precisely because it was written by a philosopher--especially of the continental flavor. Modern society cares very little about "swampy questions" which are solved only through non-technical methods like religion, art and meditation. In medicine, the vast majority of questions that have the most meaningful impact in society are studied through careful empirical, rigorous, technical analysis, from Framingham studies to the evidence based psychotherapy modalities. Even in normative fields like ethics and law, the evolving approach involves schools like "law and economics" and quantitative methods. Most of the policy documents anywhere from the federal budget to the supreme court decisions are literally filled with empirical data, expert opinions, literature, statistics, etc...

Any attempts to justify an inability to process quantitative, evidence based literature is no-longer tenable for any professional based on the "trivial to society" argument. In fact, it's easy to argue that non-technical disciplines are more or less "unimportant" to our society, as humanities department's budgets/enrollments are continually being cut--Stanley Fish has written extensively on this subject. From a social welfare perspective, the study of any of the "swampy" disciplines affords relatively value to society. Obviously, a PhD in English Literature has some aesthetic value that is not readily addressed by social welfare, but that's a separate issue.

One of us is missing the point of this passage. I did not see it as an "all who are with me step across this line" call to arms to reject scientific rigor.

Where in the passage did the author attempt "to justify an inability to process quantitative, evidence based literature." Had he done so, I would be at your side spurning him. What was being said is that there are situations where no arsenal of research-based criteria can help.

I will tell you that the family of my 37 year-old woman who had a freak stroke and died in the ER a few days ago didn't give a damn about Framingham risk score. Similarly no rationale about smoking while using OCPs would be of interest to them.

I defy you to design an algorithm based on rigorous review of RCTs that allows me to stay on the "high ground" in that situation. Which study could have led me to be certain that taking taking the husband's hand and sitting there quietly looking at the floor for 10 minutes is a better path than saying "I'm sorry for your loss" and walking out of the room?

This is an extreme example, but that is what I take from the passage. We will be swamped with situations as practitioners of medicine--especially in psychiatry--where instinct, cunning, and TRUE empathy (not the practiced type that has been "shown in dozens of studies" to be effective) will get us through and be of benefit to our patients even had we never sat for a single course on rational interpretation of the literature on effective physiological therapy of disease.

Spoken like a true lit major, I know 😛

 

[dl2dp2]

While I applaud your sensitivity we are talking past each other. The Point of the original passage, if we are to do an exegesis for entertainment is that society values "soft" disciplines more. I'm simply saying that this is no longer factually correct. Modern societies especially the one we live in just doesn't value that stuff as much. you can fight it. You can move. You can deal with it. All of which are legit options. Ignoring this fact, though, isn't.

One of us is missing the point of this passage. I did not see it as an "all who are with me step across this line" call to arms to reject scientific rigor.

Where in the passage did the author "to justify an inability to process quantitative, evidence based literature." Had he done so, I would be at your side spurning him. What was being said is that there are situations where no arsenal of research-based criteria can help.

I will tell you that the family of my 37 year-old woman who had a freak stroke and died in the ER a few days ago didn't give a damn about Framingham risk score. Similarly no rationale about smoking while using OCPs would be of interest to them.

I defy you to design an algorithm based on rigorous review of RCTs that allows me to stay on the "high ground" in that situation. Which study could have led me to be certain that taking taking the husband's hand and sitting there quietly looking at the floor for 10 minutes is a better path than saying "I'm sorry for your loss" and walking out of the room?

This is an extreme example, but that is what I take from the passage. We will be swamped with situations as practitioners of medicine--especially in psychiatry--where instinct, cunning, and TRUE empathy (not the practiced type that has been "shown in dozens of studies" to be effective) will get us through and be of benefit to our patients even had we never sat for a single course on rational interpretation of the literature on effective physiological therapy of disease.

Spoken like a true lit major, I know 😛

 

[strangeglove]

One of us is missing the point of this passage. I did not see it as an "all who are with me step across this line" call to arms to reject scientific rigor.

Where in the passage did the author "to justify an inability to process quantitative, evidence based literature." Had he done so, I would be at your side spurning him. What was being said is that there are situations where no arsenal of research-based criteria can help.

I will tell you that the family of my 37 year-old woman who had a freak stroke and died in the ER a few days ago didn't give a damn about Framingham risk score. Similarly no rationale about smoking while using OCPs would be of interest to them.

I defy you to design an algorithm based on rigorous review of RCTs that allows me to stay on the "high ground" in that situation. Which study could have led me to be certain that taking taking the husband's hand and sitting there quietly looking at the floor for 10 minutes is a better path than saying "I'm sorry for your loss" and walking out of the room?

This is an extreme example, but that is what I take from the passage. We will be swamped with situations as practitioners of medicine--especially in psychiatry--where instinct, cunning, and TRUE empathy (not the practiced type that has been "shown in dozens of studies" to be effective) will get us through and be of benefit to our patients even had we never sat for a single course on rational interpretation of the literature on effective physiological therapy of disease.

Spoken like a true lit major, I know 😛

While it is admirable that you chose the high ground in this situation, psychiatrists, how do you know that holding this person's hand was helpful?

 

[billypilgrim37]

I would argue that the original quote simply displays an ignorance of evidence-based medicine. It sets up a straw man. Maybe the problem is that med students are stupid at math, because they think that math is calculus instead of probability theory.

People still talk about limitations in studies as if they are the first person to ever think such a thing. Griping about limitations in studies is like griping about all that pesky nitrogen in the air that we can't breathe. People worry so much about what they CAN'T say from a study that they forget about what they CAN say from it.

If your journal club feels like a game of Gotcha, you aren't reading papers right.

 

[Indryd]

While it is admirable that you chose the high ground in this situation, psychiatrists, how do you know that holding this person's hand was helpful?

I don't, and can't, know. That's my point.

There is no algorithm for such situations, and they must be handled case-by-case with creativity and sensitivity. That is the author's point.

 

[Indryd]

While I applaud your sensitivity we are talking past each other. The Point of the original passage, if we are to do an exegesis for entertainment is that society values "soft" disciplines more. I'm simply saying that this is no longer factually correct. Modern societies especially the one we live in just doesn't value that stuff as much. you can fight it. You can move. You can deal with it. All of which are legit options. Ignoring this fact, though, isn't.

While I appreciate your condescension, you are reading your own meaning into the passage. That is called "eisegesis," not "exegesis."

Again, the passage does not spurn rigor and/or scientific pursuit and practice. Nor does it claim society does not value scientific rigor. You are obviously coming at this with a gigantic chip on your shoulder. It would have taken you two seconds to look into the context of the passage.

The point is NOT that society values "soft" disciplines more, it is that in practice, physicians, and other professionals are in danger of undervaluing those "soft" disciplines, disciplines which have always been central to the "practice" of medicine (as opposed to the theory behind it), whether physicians acknowledge it or not.

This is especially true, according to the passage in context, when it comes to the countless situations we will encounter that fall outside the technical algorithms developed for us by the rigors of science. In those situations, it is our creativity and cunning, our willingness to mire through the swamp of the unknown, that gets us through those situations.

By the way, you put the word "soft" in quotes, as if to disown it, and as if you were quoting the author. Again with you and your eisegesis.

The passage, in context:

"We can readily understand, therefore, not only why uncertainty, uniqueness, instability, and value conflict are so troublesome to the Positivist epistemology of practice, but also why practitioners bound by this epistemology find themselves caught in a dilemma. Their definition of rigorous professional knowledge excludes phenomena they have learned to see as central to their practice. And artistic ways of coping with these phenomena do not qualify, for them, as rigorous professional knowledge.

This dilemma of 'rigor or relevance' arises more acutely in some areas of practice than in others. In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a
swampy lowland where situations are confusing 'messes' incapable of technical solution. The difficulty is that the problems of high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are the problems
of greatest human concern. Shall the practitioner stay on the high, hard ground where he can practice rigorously, as he understands rigor, but where he is constrained to deal with problems of relatively little social
importance? Or shall he descend to the swamp where he can engage the most important and challenging problems if he is willing to forsake technical rigor?"

and later:

"Among philosophers of science no one wants any longer to be called a Positivist, and there is a rebirth of interest in the ancient topics of craft, artistry, and myth topics whose fate Positivism once claimed to have sealed. It seems clear, however, that the dilemma which afflicts the professions hinges not on science per se but on the Positivist view of science. From this perspective, we tend to see science, after the fact, as a body of established propositions derived from research. When we
recognize their limited utility in practice, we experience the dilemma of rigor or relevance. But we may also consider science before the fact as a process in which scientists grapple with uncertainties and display arts of
inquiry akin to the uncertainties and arts of practice.

Let us then reconsider the question of professional knowledge, let us stand the question on its head. If the model of Technical Rationality is incomplete, in that it fails to account for practical competence in 'divergent' situations, so much the worse for the model. Let us search, instead, for an epistemology of practice implicit in the artistic, intuitive processes which some practitioners do bring to situations of uncertainty, instability, uniqueness, and value conflict."

 

[dl2dp2]

This is kind of a slippery slope you are sliding. I actually personally not a big fan of our modern condition of overvaluing of technocrats and undervaluing of arts and aesthetics, and I don't think I was being "condescending".

However, I believe that your inclination that medicine should be practiced with "instinct" and "cunning" can be very dangerous. It is true that in medicine we can't help but use instincts at times, but I would argue that this should be minimized and is not at all the ideal situation. Medicine is, at the end of the day, not writing a novel or acting in a play. There is a right answer--even though sometimes we just don't know what it is.

And while saying that you need more "instinct" and "creativity" may sound borderline ok in some subfields of psychiatry (i.e. psychodynamics), let's substitute what you are saying to a different medical specialty: If I have a heart attack, and a scenario comes up where an algorithm doesn't exist, do I want my cardiologist to be "creative" and practice some therapy of unclear efficacy on me? Not unless it's passed the stringent equipoise litmus test of clinical experimentation. It's precisely this kind of unchecked supposedly "creative" practice that directly led to racist experimentation of Tuskegee. Clinician judgments are shown time and time again to be colored strongly by racist, sexist, culturally specific biases and should be as minimized as possible. You don't have to believe it. It's just a fact of reality and a consensus. Medical ethics and the sociological and anthropological study of medicine have been moving in the exact same direction that I have articulated--rigor, data, evidence.

Sure occasionally there are some Hail Marys in medicine where creativity saves lives, but this is and should be very far from everyday practice.

We can have a whole other conversation about where philosophy is going, and experimental philosophy and so forth. But the point of the fact is, the dichotomy between rigor and relevance is a false dichotomy. Whatever is relevant has to be rigorous.

While I appreciate your condescension, you are reading your own meaning into the passage. That is called "eisegesis," not "exegesis."

The point is NOT that society values "soft" disciplines more, it is that in practice, physicians, and other professionals are in danger of undervaluing those "soft" disciplines, disciplines which have always been central to the "practice" of medicine (as opposed to the theory behind it), whether physicians acknowledge it or not.

 

[kugel]

However, I believe that your inclination that medicine should be practiced with "instinct" and "cunning" can be very dangerous. It is true that in medicine we can't help but use instincts at times, but I would argue that this should be minimized and is not at all the ideal situation. Medicine is, at the end of the day, not writing a novel or acting in a play. There is a right answer--even though sometimes we just don't know what it is.

At least 80% of the pts I see every day do not fit into any known algorithm, nor is there are any good, well-controlled, RCT to to address the complexity and comorbidity involved. Every day I have to come up with a creative and cunning way to find a way to help these people in a format that they can accept.

I could simply throw up my hands and either A) do what has already been done to/for them several times with no benefit (or, indeed, demonstrable harm) or, B) do nothing because either there is no clear answer or because the patient will not permit the more obvious choices.

I choose to try to help. Often, this means trying desperately to get the pt to accept the more conventional and safer choice for treatment - and coming up with some pretty creative ways to do that. Other times, I have to come up with the treatment plan that comes as close to "standard" treatment as the pt will allow - but one for which there is no clear and convincing evidence.

If I have a heart attack, and a scenario comes up where an algorithm doesn't exist, do I want my cardiologist to be "creative" and practice some therapy of unclear efficacy on me? Not unless it's passed the stringent equipoise litmus test of clinical experimentation.

You would rather (s)he did nothing, instead of explain that we are outside the known "correct answers" and that "these are the reasons that I recommend the following course...?"

It's precisely this kind of unchecked supposedly "creative" practice that directly led to racist experimentation of Tuskegee.

I'm sorry, but I'll never believe that was "medical judgment." It was the assumption that some people (esp. minorities) are expendable if doing so benefits the majority.

Clinician judgments are shown time and time again to be colored strongly by racist, sexist, culturally specific biases and should be as minimized as possible. You don't have to believe it. It's just a fact of reality and a consensus.

That's such a ridiculous over-generalization that I can't find an adequate response. I'll just say simply that Clinical judgments should NOT be as minimized as possible. We treat the patient; not the labs or the algorithm. We use everything we can find to help inform our judgment, and the more rigorous the science and the closer it is to the clinical situation at hand, the better.

 

[OldPsychDoc]

At least 80% of the pts I see every day do not fit into any known algorithm, nor is there are any good, well-controlled, RCT to to address the complexity and comorbidity involved. Every day I have to come up with a creative and cunning way to find a way to help these people in a format that they can accept.
...
That's such a ridiculous over-generalization that I can't find an adequate response. I'll just say simply that Clinical judgments should NOT be as minimized as possible. We treat the patient; not the labs or the algorithm. We use everything we can find to help inform our judgment, and the more rigorous the science and the closer it is to the clinical situation at hand, the better.

👍
Where is that doggone "Like" button on SDN?

 

[cleareyedguy]

I strongly agree that we do the best we can with what we have, that we have to adapt algorithms and available data to the patient, and I agree that it's hard to do without inducing harm or being reductionistic or financially self interested at the expense of the patient.

I would, however, argue that there is a huge knowledge gap between the best of our practitioners/researchers and the people who don't vigorously keep up with the literature (and keep up with their own countertransference and/or refuse to accept a biopsychosocial perspective by focusing too much on pills, analysis, etc to the exclusion of the others). It is one of the reasons that I think it's important to study hard in medical school, to go to a challenging residency program, to set yourself up for a marathon career that also requires a certain amount of sprinting and scrambling. From what I've seen among my patients, friends, and family, there are psychiatrists (and other mental health professionals) who do a very bad job, who misapply their misinformation, and hurt the people who they are entrusted to help.

 

[strangeglove]

I don't, and can't, know. That's my point.

There is no algorithm for such situations, and they must be handled case-by-case with creativity and sensitivity. That is the author's point.

So, then, why did you do it?

 

[Indryd]

So, then, why did you do it?

First of all, I did not say what I did in this situation. I laid out a couple of conceivable courses of action that may or may not have been the most appropriate choice for the situation. Another choice might have been to say "Don't be a *****," or "If you are going to be a while, do you mind if I step out?" or "Do you know Jesus Christ as your personal Lord and Savior?"

The point was to illustrate that there are situations for which science has not created an algorithm for cookbook doctors to follow.

While it is admirable that you chose the high ground in this situation, psychiatrists, how do you know that holding this person's hand was helpful?

Second of all, you are not understanding what what is meant by "high ground" in this discussion.

In my illustration, one course of action is not the "high ground" and the other the "low ground;" this is not, in this case, meant as a metaphor for some moral basis for decision making where the "high ground" is one course and the "low ground" is the other.

If you would read the passage, especially in context, you would understand that the author uses "high ground" to mean the "safe ground"--the areas of practice that DO fall perfectly into our diagnostic and treatment algorithms, and where we can easily predict outcomes and be guided strictly by the results of RCTs and such.

Likewise, the "low ground" refers to an area where, according to the author, many modern practitioners are afraid to go. It is an area of practice that is filled with uncertainty, complexity, even frank confusion. It is an area where no algorithms exist and no RCTs have been performed that can be relied upon to guide one's decision making.

 

[Psych2014]

I love the original concept of this thread.

I'll admit right up front that I am not as intelligent and fluent in scientific theory or philosophy as you all, I'm not made that way. I love to learn science, but I've seen the human being defy it more often than not in the realm of healing the mind and "heart" (a loosely used term).

I wonder if what some here are trying to say, and what I fully believe is... science, evidence, accurate diagnosis, and treatment are our duty, and are extremely important, but at the end of the day, LOVE may be the most important of all...the kind of love and personal risk it takes to just stand with someone, saying nothing. I know love is a word we rarely say to our patients, it is too loaded. But it is a word for something they either see in us, or don't, and their heart then either opens or closes to what we say and give. And, oddly, there is research on the neurobiology of an open or closed heart (ptsd, etc.). Yet, I dont' believe love is required to be a good doctor in any discipline. Medicine is helpful with or without "love".

 

[OldPsychDoc]

It would be interesting to hear from zenman just what his intent was in posting that quote.

To me, it is not "love" vs. "science", which brings all sorts of false dichotomies into our practice, but a recognition that for all the rigor of our RCTs, we deal with individual patients in a "real world" that actually has to be controlled out of those RCTs. And so many of our patients are literally in the "low ground" socioeconomically...practicing here involves more swamp survival skills than academic accolades. The latest FDA indication for Cymbalta, or the newest enantiomer du jour, means little to the woman who is experiencing a cascade of bounced checks and bank fees because a state aid check bounced, and who must borrow to pay for the gas to drive to her clinic appointment.

 

[Psych2014]

Right, I was not putting up love vs. science, or relationship (which obviously is the treatment) vs. treatment, but writing about a certain power that love, or relationship, or trust has, in turning some hidden key in the woman's heart, to possibly help her to believe, and then see some new practical solutions to her credit card debt, or the implications of the next time she considers calling her drug dealer, or hitting her child. There's a bit of mystery here, which is wonderful, frustrating, beautiful, and I seriously doubt science will ever quanitfy it, and yet I believe it may be more powerful than anything else we can offer. And yet, in the end, a schizophrenic needs AP's and a BP needs his meds also, no amount of "love" is going to eradicate that, but it may seriously alter the course of it.

 

[nancysinatra]

It would be interesting to hear from zenman just what his intent was in posting that quote.

To me, it is not "love" vs. "science", which brings all sorts of false dichotomies into our practice, but a recognition that for all the rigor of our RCTs, we deal with individual patients in a "real world" that actually has to be controlled out of those RCTs. And so many of our patients are literally in the "low ground" socioeconomically...practicing here involves more swamp survival skills than academic accolades. The latest FDA indication for Cymbalta, or the newest enantiomer du jour, means little to the woman who is experiencing a cascade of bounced checks and bank fees because a state aid check bounced, and who must borrow to pay for the gas to drive to her clinic appointment.

I think the problem in psychiatry happens on a lot more basic level than just not being able to implement RCTs all the time. Even if RCTs could be theoretically applied in every treatment situation, we would still have a lot of ambiguity to deal with in psychiatry. After all, RCTs relate to treatment, which is the last step in a chain of clinical thinking. But before that, there are other steps. In diagnosing patients, things are often unclear, and in psychiatry we do not have many definitive tests. How often do I see patients who come in with "Bipolar d/o, Schizophrenia, and Schizoaffective d/o?" (It drives me crazy that actual psychiatrists let this stuff happen! It should be illegal with an increasing fine attached for each instance! So should discharges with unnecessary NOS diagnoses! Seriously, fines are the only way to stop egregious problems.)

But even on a more basic level than that, things can be ambiguous. For example, we might ask patients if they are "hearing voices." I've been reading Simm's Symptoms in the Mind, which is excellent for describing psychopathology. And I've had a course on the subject and many conversations with attendings and other residents, and I've asked many patients in excruciating detail what kinds of "voices" they're hearing. So you'd think I might be able to tell, just once! But NO! I cannot tell for sure if this is happening to anyone, although there certainly are clues, such as a person responding to internal stimuli, or acting on command auditory hallucinations, and of course, the things the patient tells me. But a Borderline patient will say they hear voices every day of their life, and I REALLY doubt that. A malingerer will say the same. A patient with tinnitus or a hearing abnormality might answer that they are hearing things too. So... it's subjective. As far as I know there is no test or algorithm. I suppose this type of subjectivity is part of the reason there are people walking around with psychotic diagnoses who in fact have something else going on. And this is way before the point of applying results of an RCT.

As frustrating as these situations in psychiatry are, I think there are parallels in other areas of medicine. For example, if you ask patients about chest pain, like what kind of pain it is and where it is radiating, that gets really mucky too. Someone once told me that those questions are actually not very reliable. The difference there is, they can follow up with tests to confirm/deny what the patient says. Whereas we don't have many tests. And just as a gross generalization--medical/surgical patients don't have the same rates of social problems that psych patients do. Nor do they face the same stigma. So psychiatry faces these unique ambiguous problems, and then a difficulty to implement whatever solutions have been shown to work.

Personally I see that as a challenge to address--not by "running away" from science or taking up romance novels or whatever, but by using whatever tools can be applied to the problem. For example, it is up to us to be more accurate in making correct diagnoses, and in adding as much clarity to situations as we can. Maybe one day someone will develop an algorithm (or at least a really great approach!) for dealing with the non-compliant patient. I mean, who knows?! And people should be advocating for social support for the mentally ill... which might improve compliance somewhat. I'm just saying, clearing the picture where we can will lead to less muck where it isn't needed, so we can apply research to the remaining scientific questions.

In any case, with a question like the one the OP asked, you are going to get different answers from different people...

 

[zenman]

It would be interesting to hear from zenman just what his intent was in posting that quote.

Damn if I know; just thought it interesting.The quote was in the book, "Healing Psychiatry:Bridging the Scientific/Humanism Divide."