INTRODUCTION

Knowledge is an essential component of clinical reasoning. In this chapter we take the view that knowledge is both a tool and a sociocultural historical phenomenon. To explore and substantiate this view we locate this argument as follows:

This framing of knowledge was recently examined in two research projects. The first investigated the evolution of practice knowledge in a disciplinary context (Larsen 2003, Larsen et al 2003). The second explored the place of sociocultural, historical frameworks and practice communities in developing the ability of practitioners to use practice knowledge in clinical decision making (Loftus 2006, Loftus & Higgs 2006). Both projects identified the importance to professional practice of the way knowledge is construed. Understanding knowledge as a sociocultural historical phenomenon enabled Dale Larsen (2003) to examine in detail the nature, depth and changing patterns of knowledge that practitioners (in manual therapy) have used to support their practice, to produce a rational and rich contextual framework of the knowledge practitioners currently use in this discipline, and to provide a critique of the forms and origins of knowledge used. This, it is argued, is one of the responsibilities of professionals: to understand and critique the knowledge they use in practice. Stephen Loftus (2006) identified the substantial influences of sociocultural factors and the personal history and socialization experiences of individual practitioners and students on the way they understand what knowledge is and how they use and name it in practice. From his work (see also Chapter 31) we can identify the importance of understanding knowledge as a key tool for decision making and practice actions in the changing sociocultural and historical worlds of practice.

LOCATING KNOWLEDGE, REASONING AND PRACTICE WITHIN SOCIOCULTURAL FRAMES OF REFERENCE

Professions are practice communities that evolve in sociocultural, political and historical frames of reference. They are occupations constantly in search of greater professionalization. They are influenced by forces from within, such as a drive towards self-regulation and autonomy. In addition, they are driven by a need for external recognition, the pursuit of ongoing credibility and viability in the marketplace, the desire for recognized status and respect in a competitive practice arena, and an ongoing drive towards continued development of their knowledge base and practice.

Professions face many external influences, including changing demographics, the expectations and demands of society and consumers, perpetually fluctuating economic and political demands of governments and employers, and persistent changes in the resources and demands of their knowledge, physical, technological and human worlds. Practitioners endeavour to locate and pursue their reasoning, knowledge evolution and use, and their practice in these contexts. In turn, it is their knowledge, reasoning and practice that help more broadly to shape their practice communities, the world of healthcare practice and society. For example, multicultural communities often seek a mixture of healthcare services, blending traditional practices of different cultural groups and mainstream medicine. In the health sector there is a matching trend to provide services which combine (through referrals or integrated practices) mainstream and complementary medicine approaches (Grace et al 2006).

CLINICAL REASONING AND KNOWLEDGE AS ACCULTURATED PHENOMENA

For centuries, Western thought was dominated by the Cartesian notions that reasoning and knowing were essentially activities of individuals operating in isolation. These ideas have been challenged in recent decades by scholars such as Vygotsky (1978, 1986) and Bakhtin (1986). In their view reasoning and knowing begin as activities embedded in social interaction; they are primarily intersubjective processes provided to us by our culture. They become gradually internalized by individuals who can then use such knowledge and reasoning for themselves. We become acculturated into societies that provide us with a cognitive toolkit of knowledge and ways of using such knowledge. Professionalization can be viewed as a specialized form of this acculturation. Professional education and training are primarily about socializing students into particular ways of knowing and thinking about the world of practice.

In Vygotskian terms, professional ways of thinking and knowing are higher mental functions. Vygotsky (1978) distinguished higher mental functions from the lower mental functions which we share with animals. He claimed that higher mental functions, which would include clinical reasoning, are qualitatively different from the lower, and cannot be reduced to them. Higher mental functions need a different conceptual framework, one that takes into account their cultural and historical nature. Unfortunately, the dominant cognitivist and behaviourist paradigms within fields such as professional and clinical reasoning are reductionist, and so have been unable adequately to conceptualize the issues involved in such higher mental functions. Schön (1987) addressed another aspect of this problem when he discussed the way that language, in the form of our terminology, has been used to close off inquiry. He contended that the observation that outstanding practitioners have more wisdom, or talent, or artistry should be the point from which we can open up inquiry into the nature of these concepts. In fact, these terms are often used to bring inquiry to an end, as concepts such as artistry and talent do not fit within the domain of propositional knowledge. The cognitive paradigm is based upon a metaphor of the mind as a computer. Concepts such as artistry, talent and wisdom have no place within this metaphor, and therefore become effectively invisible to those who think this way. Cognitivism admits knowledge in one form only, that of technical rationality.

However, there is a growing realization that knowledge and rationality can be conceptualized in different ways. Wells (2000), taking a Vygotskian viewpoint, differentiated five types of knowledge: instrumental, procedural, substantive, aesthetic and theoretical. These are said to form an ascending hierarchy of more and more sophisticated forms of knowledge. From this perspective, these different forms of knowledge have emerged over the course of human history as a result of the development of culture that requires people to engage in various activities. The Western world has been dominated by one model of rationality for several centuries, the model of rationality based upon science. Consequently, the health professions have come to view themselves as sciences when it could be argued they should be seen as scientifically informed practices (Montgomery 2006). A science and a scientifically informed practice are quite different. Lawyers might use forensic science in a courtroom but they are not scientists; they are scientifically informed practitioners. Montgomery (2006) argued that medicine (and by implication all health professions) should be seen in the same way, emphasizing that there are other ways than scientific technical rationality of being rational. She discussed notions such as Geertz’s (1983) insights into so-called ‘common sense’. Geertz observed that the common sense of a culture might be obvious to people immersed in that culture. However, on closer examination it is quite clear that common sense is a sophisticated body of knowledge. According to Montgomery (2006), health professionals often ascribe their expertise to common sense, forgetting that it is a hard-won common sense, available only to insiders in the profession. It is a form of rationality that is ‘culturally engendered’ and ‘communally reinforced’ (p. 165). The phronesis, or practical rationality, of Aristotle is a closely related notion. This is the difficult to articulate knowledge acquired only through the experience of doing one’s practice. Professional craft knowledge (Higgs & Titchen 1995) is a related concept.