Review

An art or a science?

Clinical Judgement in the Health and Welfare Professions
Susan White and John Stancombe
McGraw-Hill Education, 2003. £18.99

The question whether clinical judgement is an art or a science involves complex politics. On the one hand, the idea of medicine (usually) and other clinical disciplines as cold, formal and scientific, based on extensive training and excluding human relationships, is often resented by patients. On the other, the alternative view that professionals practise esoteric skills and can only be judged by their peers makes the power relationship still more one-sided.

Organisationally, the same dilemma arises in evaluating evidence-based practice. It can be a way of imposing rationing and excluding patient and public intuition (the MMR issue), but can also be a way of controlling mavericks (the Bristol cardiac issue).

The authors take a balanced position, seeing professional practice as both art and science. The book works by examining how judgements are actually made and exploring how subjectivity determines the formulation of questions and interpretation of results. It relies heavily on transcription of examinations, discussions, therapy sessions and case conferences, which makes it very readable.

There are interesting examples, even from the ‘hard’ end of diagnosis, illustrating how something such as the interpretation of a child’s X-ray can be affected by general views about the family. Unsurprisingly, however, most of the case studies involve psychiatry, potential abuse and diagnostic categories such as Munchhausen’s disease by proxy.

These demonstrate how professionals base questions and interpret results in the light of conscious or unconscious presumptions and how, similarly, they control the answers which patients can give them.

It is unclear, however, whether this should be seen as an inevitable result of the interaction between theory and practice or as a fault. Certainly the reader finishes most of the case studies with a sense of annoyance at the obtuseness and bias shown by the professionals. The question is whether they should have done better and, if so, how.

At the end, the reader is left with a suspicion that the book was written with an ironical purpose. The authors have set out to make their point by doing to the clinicians what the clinicians do to their patients. This makes the book interesting and entertaining but not necessarily very useful.