The strength of medicine as a profession is that it values knowledge. It is a learned profession. It admires expertise and experience. While true, this characterization can also be understood as a weakness: To know is to act.Knowledge is virtue. For the benefit of analysis we can view medicine’s epistemology as consisting of two paradigms.
Prolific Knowledge is the traditional paradigm that focuses on how much we know. What we know is not the same as how we think. But in medicine it is true that the more we know the better we think. This the underlying logic of prolific knowledge.
Profound knowledge is the foundation of improvement. It combines disciplinary knowledge such as medicine, nursing etc with knowledge for improvement: Systems Thinking, Statistical Thinking, Epistemology and Psychology.
Clinical practice depends on two related issues: what is true i.e. evidence and what you do. Unfortunately, there is a gap between the two and is recognized as the Knowing- Doing Gap.
The Evidence Based Medicine [EBM] movement was a response to the problem of information overload and the difficulty in identifying applicable evidence. It depended on critical thinking or better ways of knowing.
Improvement science augments EBM by addressing the problem from the action side. It is dependent on design learning or learning by doing.
Medicine is currently founded on Decision.The missing epistemology is Design: an explicit epistemology of collective action, execution, strategy or implementation. Decision based practice is dependent on ‘confirmatory research'[dominated analysis using text and symbols], while design based practice requires ‘creative research'[driven by synthesis using graphics, space and time]. While the substrates remain the same – provision of care- the directions are apposite , decisions are deductive and involve forward reasoning , design is abductive and requires backward reasoning.
The knowledge is virtue paradigm views theory and practice as distinct and is believed to breakdown due to weakness of will or ‘akrasia’ as Aristotle emphasized. The design paradigm lies close to the practice end of the continuum, sees action and evaluation as in-separable and thus is creative.
To some extent we can place the two epistemologies in two worlds that Herbert Simon posited. Decisions in the natural world with the patient – professional interaction as the elemental level and design in the artificial world , with what Batalden et al prefer to call as micro-systems, as the atomic unit.
Keywords: Learned Profession, Prolific Knowledge, Profound Knowledge, Knowing- Doing Gap, Decision, Design, Confirmatory Research, Creative Research, Analysis, Synthesis, Akrasia, Forward Reasoning , Backward Reasoning, Deduction, Abduction, Natural World, Artificial World .1