This book addresses a relevant issue which has been largely overlooked in health sciences until recently. ‘Knowledge-in-practice’ or ‘practice-wisdom’ refers to the professional know-how of actual clinical practice as opposed to the theoretical knowledge or know-what.
The tension between know-what and know-how is not new. The introduction and Chapters 1 and 2 provide an excellent review of the origins of this debate. Jacobs introduces in Chapter 1 the Greek term ‘Metis’ as equivalent to everyday practices. The meaning of Metis is very complex and may not have a single word equivalent in English. Homer used this term to describe Odysseus, as crafty, skilful, and resourceful. The equivalent of Odysseus in Greek mythology is the Titan Prometheus—also derived from metis—who surpassed his brothers in practical intelligence and knowledge. Plato's dialogue ‘Meno’ advances a theory of knowledge. There Socrates asks Anytus:
“If we wanted Meno to be a good physician, to whom should we send him? Should we not send him to the physicians?… if we wanted him to be a physician, do we mean that we should be right in sending him to those who profess the art, rather than to those who do not…?”
The origins of practical knowledge are further clarified by Peter Greenberg in Chapter 2, who explains that “Aristotle in his Nichomachean ethics distinguishes two sorts of wisdom, ‘sophia’ (science) which discerns why the world is the way it is, and ‘phronesis’, which incorporates the principles of ‘sophia’ to act in practical situations, based on experience.” Thus phronesis involves both theoretical and practical knowledge.
Tacit knowledge is another relevant topic in Chapter 1. Unfortunately, hybrid approaches which incorporate qualitative methods, classical statistics and artificial knowledge such as ‘Knowledge Discovery from Data’ (KDD) are not mentioned as key strategies to formally incorporate tacit or implicit knowledge to data analysis [1].
Chapters 1 and 2 also deal with the conflict between experience-based knowledge and evidence-based medicine. This complementary and thoughtful narrative warns us of the risks of discarding practical knowledge as a valuable information source in health sciences. Traditionally, medicine combined theoretical knowledge and experiential knowledge both in training and clinical practice although practical-knowledge provided very little feedback on the medical ‘corpus doctrinae’. In 1983, Professor Hampton announced the death of clinical freedom [2] and this was followed by the increasing influence of evidence-based medicine particularly after 1997, when the seminal book by Sackett et al. was published [3] and EBM became a MeSH medical subject. Since then experiential knowledge is regarded as a source of bias rather than a source of knowledge.
The adoption of evidence-based practice (EBP) as the basis of clinical practice has brought a considerable unbalance of the know-what and know-how components of medical care. As the editors state in the introduction, EBP tends to “rely only or primarily on ‘evidence’ that has been produced through experimental science models that include randomised control trials. The increasing tendency to gauge professional efficacy according to the principles of experimental science models has generated significant professional and scholarly debate about what is to count as evidence, and how different forms of evidence are to be graded in different research and practice paradigms” (p. 3). As exclusion and inclusion criteria are carefully defined in randomized control trials to reduce the complexity of the phenomena observed, the overall value of the restrictive experimental approach decreases as the levels of complexity of the analyzed phenomenon increases; particularly in highly complex situations as those occurring when organisations behave as a complex adaptive system [4]. Under conditions of uncertainty expert knowledge is a useful complementary information source for medical decision-making. Greenberg's discussion on the problems of EBP in healthcare is in agreement with a recent document on systems thinking edited by the WHO Alliance for Health Policy and Systems Research [5].
After this excellent overture, the interest of the book decreases when dealing with special professions and healthcare areas, probably as a consequence of the lack of a content structure common to the different areas, the different views on a new field, and the specific focus on Australia whilst a broader perspective might have improved the global applicability of the book. The specific areas covered are psychiatry, social work, disability, analytical psychology, nursing, obstetrics, and person-centered care. A number of chapters illustrate how relevant knowledge acquired in one area may have practical applicability in other areas of healthcare. Chapter 10 discusses the concepts of shared-cared and blending-of-knowledge and provides an interesting example of two different disciplines—physiotherapy and occupational therapy—over care of patients suffering stroke. In Chapter 11 Peter Miller offers interesting examples of the links between experienced-based knowledge and care models and interventions for drug addiction.
In summary, “Knowledge-in-practice in the caring professions” is a seminal although incomplete book for the development of a comprehensive approach to healthcare which incorporates expert-driven knowledge as a valuable information source. “Can you tell me, Socrates, how does one achieve excellence in clinical medicine?” asked George Dunea in his 1973 Socratic dialogue: “it is neither from teaching nor from practice that our young people will derive much benefit, unless we can also inspire them by example as well as by precept to strive for that state of excellence which their souls should desire.” (p. 6)