Tanenbaum S J
Division of Health Services Management and Policy, College of Medicine and Public Health, Ohio State University, Columbus 43210-1234, USA.
Acad Med. 1999 Jul;74(7):757-63. doi: 10.1097/00001888-199907000-00008.
The outcomes movement--including evidence-based medicine--challenges medicine as a profession by disputing what and how physicians know. First, the movement considers probabilistic research to be virtually the only way to arrive at knowledge in medicine. Second, it insists on objective or impersonal knowledge (statistically manipulated, hard, aggregate data). Such knowledge does not come from within the professional relationship; rather it is gathered across relationships and is offered to the practitioner from the outside. Third, the outcomes movement is motivated by a desire for certainty, promising definitive solutions that will reduce variation and waste. What professionals know, in contrast, is inherently and irreparably uncertain. Fourth, the movement expects physicians to implement the findings from probabilistic research through application. The inferential leap necessary for treating an individual based on aggregate findings is mostly assumed away. Finally, the outcomes movement promotes rule-based behavior on the part of physicians in an effort, among other things, to eliminate variation in medical practice. But professionals do not follow rules per se--they intuit what is right in a situation, including, sometimes, that it is right to defer to a rule. Professional knowledge in medicine is both larger and smaller than the knowledge conceived of by the outcomes movement. The latter is built of probabilistic research and translated into physician directives. Professional knowledge, in contrast, partakes of statistical knowledge and bench science, as well as various forms of personal knowledge, including the experiential. Physicians will continue to need professional knowledge, which allows for the complexity of physician experience and for the immediacy and individuality of patients.
结果导向运动——包括循证医学——对医学作为一门专业提出了挑战，它质疑医生所知道的内容以及知晓方式。首先，该运动认为概率性研究几乎是医学获取知识的唯一途径。其次，它坚持客观或非个人化的知识（经统计处理的、确凿的、汇总的数据）。这类知识并非源自专业关系内部；相反，它是通过多种关系收集而来，并从外部提供给从业者。第三，结果导向运动的动机是对确定性的渴望，承诺提供能减少差异和浪费的明确解决方案。相比之下，专业人员所知道的内容本质上具有不可避免的不确定性。第四，该运动期望医生通过应用来实施概率性研究的结果。基于汇总结果治疗个体所需的推理跳跃大多被忽略了。最后，结果导向运动促使医生采取基于规则的行为，其目的之一是消除医疗实践中的差异。但专业人员并非仅仅遵循规则——他们凭直觉判断在某种情况下什么是正确的，有时包括遵循规则是正确的这一点。医学中的专业知识比结果导向运动所设想的知识既宽泛又狭窄。后者由概率性研究构建而成，并转化为医生的指令。相比之下，专业知识包含统计知识、基础科学以及各种形式的个人知识，包括经验知识。医生将继续需要专业知识，因为它能兼顾医生经验的复杂性以及患者的即时性和个体性。
