The Uses and Limitations of Pragmatism.

An action is judged by the result. Research as an activity provides a warrant only for efficacy. Efficacy is not the same as effectiveness. Evidence is not the same as ‘Effect’. This is the central problem of the epistemology of clinical practice. While there are many reasons for the research practice gap, its methodological solution has traditionally been sought at the research end of the dichotomy, in the idea of external validity or generalizability. The challenge of applicability of evidence to individual patients is again minimized by the ‘rational reconstruction’ of statistical significance as clinical significance , through methodological manoeuvres such effect size calculation, numbers needed to treat , cost effectiveness etc. Such a translation however does not meet the challenges inherent in contingent  nature of clinical practice. This constitutes a ‘broad-casting’ model of research utilization.

Attempts at the practice end of the dichotomy, have included techniques like decision analysis, but have failed ,as they demand a degree of rigor that is not affordable in day to day practice. To some extent the development and use of  guidelines and pathways allow adaptation to local condition. Such efforts at ‘research synthesis ‘ represent the ‘narrow-casting’ model of research utilization. However,  in principle , both these models of research utilization , have  the  short coming of merely extending  the procedural  ‘rationalism ‘ of the research environment  without regard to the ‘empirical’ nature of practice. The critical gaze of EBM merely adds a layer of formalism or theoretical systematization and does not redress the philosophical problem of ‘vagueness’ in the idea of practice.

Pragmatic epistemology when applied to medical practice offers a sympathetic understanding of both the above mentioned challenges. Any characterization of science consists of observations and a method of analysis. While the pragmatists introduce an element of skepticism towards both these elements , they do not throw the baby out with the bathwater as modern day relativist  would. The pragmatist primacy of action over thought makes them part of the solution. Pragmatism is not an argument against evidence but allows only a tentative epistemic worth to evidence: Evidence is evidence only if it is what works for the practice or society. Evidence is judged by its utilitarian value then it has better chance if it is a product of  practice based research or at least  practice driven research.

Improvement science , as I see it, has its sources in pragmatism [ CI Lewis’s influence on Shewart and Deming ] and in realism. The pragmatists not only treat action as primary and thought as secondary , but add an element  of economy to the process of knowing. The do not seek absolute truth but are content with the idea of utility- usefulness and meaningfulness. Their scepticism towards any foundationalism encourages a method of learning by doing.  When we draw on  realism , of the variety professed by Karl Popper , then a scientific characterization of clinical practice requires a continuous attempt to falsify the ‘theory’ of an intervention proposed by the research process, by a minimal version of the scientific method called PDSA. This is the demarcating criteria of scientific practice.

The modern dogmatic view is more prone to be foundationalism.  The typical metaphor for the architecture of knowledge is one provided by Rene Descartes in the 16th century of a physical building, that requires sound , unshakable foundation of certain knowledge , that is beyond all possible doubt  and then  from these axioms building an edifice through a chain of   deduction. This rationalist approach still dominates the evidence base movement in medicine. What may be a more accurate description of useful knowledge is the metaphor of the crossword puzzle [Foundherentistism  of Susan Haack], where research evidence integrates with other forms of knowledge eg. from experience, from context etc to provide a fruitful solution.

Thus democratization of excellence and socialization of quality is the appropriate ‘research program’ of improvement science, which are very much central themes of the pragmatic world view. From an epistemological point  of view it requires the democratization of inquiry.

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