Thomas Paul
Centre for Study of Policy and Practice in Health and Social Care, Thames Valley University, Ealing, London, UK.
Ann Fam Med. 2006 Sep-Oct;4(5):450-4. doi: 10.1370/afm.581.
When general practitioners and family physicians listen, reflect, and diagnose, we use 3 different theories of knowledge. This essay explores these theories to highlight an approach to clinical practice, inquiry, and learning that can do justice to the complex and uncertain world we experience. The following points are made: (1) A variety of approaches to research and audit are needed to illuminate the richness of experience witnessed by general medical practitioners. (2) Evidence about the past cannot predict the future except in simple, short-term, or slowly changing situations. (3) We consciously or unconsciously weave together evidence generated through 3 fundamental theories of knowledge, termed postpositivism, critical theory, and constructivism, to make sense of everyday experience. We call it listening, reflecting, and diagnosing. (4) These 3 fundamental theories of knowledge highlight different aspects within a world that is more complex, integrated, and changing than any single theory can reveal on its own; they frame what we see and how we act in everyday situations. (5) Moving appropriately between these different theories helps us to see a fuller picture and provides a framework for improving our skills as clinicians, researchers, and learners. (6) Narrative unity offers a way to bring together different kinds of evidence to understand the overall health of patients and of communities; evidence of all kinds provides discrete snapshots of more complex stories in evolution. (7) We need to understand these issues so we can create an agenda for clinical practice, inquiry, and learning appropriate to our discipline.
当全科医生和家庭医生倾听、思考并进行诊断时，我们运用三种不同的知识理论。本文探讨这些理论，以突出一种临床实践、探究和学习的方法，这种方法能够公正地对待我们所经历的复杂且不确定的世界。具体观点如下：（1）需要多种研究和审核方法来阐明全科医生所见证的丰富经验。（2）除了在简单、短期或缓慢变化的情况下，关于过去的证据无法预测未来。（3）我们有意识或无意识地将通过后实证主义、批判理论和建构主义这三种基本知识理论产生的证据编织在一起，以理解日常经验。我们将其称为倾听、思考和诊断。（4）这三种基本知识理论突出了一个比任何单一理论自身所能揭示的更为复杂、综合且不断变化的世界中的不同方面；它们构建了我们在日常情境中所见以及如何行动的框架。（5）在这些不同理论之间适当地转换，有助于我们看到更全面的图景，并为提升我们作为临床医生、研究人员和学习者的技能提供一个框架。（6）叙事的连贯性提供了一种整合不同类型证据以理解患者和社区整体健康状况的方式；各类证据提供了更复杂故事在演变过程中的离散片段。（7）我们需要理解这些问题，以便能够制定适合我们学科的临床实践、探究和学习议程。
