May Carl, Rapley Tim, Moreira Tiago, Finch Tracy, Heaven Ben
Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne, NE2 4AA, UK.
Soc Sci Med. 2006 Feb;62(4):1022-30. doi: 10.1016/j.socscimed.2005.07.003. Epub 2005 Sep 12.
Technological solutions to problems of knowledge and practice in health care are routinely advocated. This paper explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-centred clinical practice in which patients'heterogeneous experiences and narratives of ill-health are qualitatively engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but both impulses are embodied in new 'technological' solutions to the management of heterogeneity in the clinical encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up a new array of practices--technogovernance--in which the heterogeneous narratives of the patient-centred encounter can be resituated and guided.
医疗保健领域中知识与实践问题的技术解决方案经常被提倡。本文探讨了新的实践系统作为临床医生与患者互动中介的部署方式。这一分析的核心在于基层医疗中组织实践理念的两种重要方式之间明显的冲突。其一，从对患者的医学客观化转向以患者为中心的临床实践，在此过程中，患者关于健康不佳的异质经历和叙述被定性地纳入并参与到疾病轨迹管理的决策中。其二，通过循证医学的推动，揭示了大量实验对象的证据被调动起来，其中定量知识被纳入并用于指导疾病管理，并通过临床指南进行调解。这两种组织临床实践理念的方式之间的紧张关系十分强烈，但这两种冲动都体现在临床诊疗中管理异质性的新“技术”解决方案中。我们认为，技术解决方案本身体现并呈现了这些紧张关系，但也可能正在开启一系列新的实践——技术治理，即以患者为中心的诊疗中异质叙述能够被重新定位和引导的实践。
