Experiential knowledge in clinical medicine: use and justification
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Experiential knowledge in clinical medicine: use and justification Mark R. Tonelli1 · Devora Shapiro2
© Springer Nature B.V. 2020
Abstract Within the evidence-based medicine (EBM) construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians’ primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the “best” evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients. Keywords Medical epistemology · Experiential knowledge · Decision-making
Introduction Direct experience is an essential component of physician training, and the knowledge gained from such experience is a necessary element of competent medical practice. Proponents of evidence-based medicine (EBM), who privilege knowledge from population-level clinical research, note the relevance of experiential knowledge underpinning decisions about particular patients. In the most
* Mark R. Tonelli [email protected] 1
University of Washington, 1959 NE Pacific St., Box 356522, Seattle, WA 98195‑6522, USA
2
Southern Oregon University, Ashland, OR, USA
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M. R. Tonelli, D. Shapiro
widely cited definitional work regarding EBM, David Sackett and colleagues assert: The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. [1] Despite this assertion, the expansive literature of EBM remains virtually devoid of specific instruction regarding the process of integrating clinical expertise with external systematic research. Rather, knowledge gained through physician experience has continued to be devalued and de-emphasized, both explicitly and implicitly. Hierarchies of evidence, central to the epistemology of EBM, consistently place the experiential knowledge of physicians in the bottom tiers, if they include such knowledge at all [2]. So while EBM offers platitudes regarding the value of clinical experience, the state
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