University of Washington, 1959 NE Pacific St., Box 356522, Seattle, WA, 98195-6522, USA.
Southern Oregon University, Ashland, OR, USA.
Theor Med Bioeth. 2020 Jun;41(2-3):67-82. doi: 10.1007/s11017-020-09521-0.
Within the evidence-based medicine (EBM) construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians' primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the "best" evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients.
在循证医学（EBM）结构中，临床专业知识既源自于主要经验，也是优化医疗实践所必需的。然而，医学实践中的主要经验仍然被低估。EBM 倾向于将临床医生的主要经验视为非系统性或轶事性的，是偏见的来源，而不是知识的来源，它永远不能作为支持临床决策的“最佳”证据。认为临床专业知识是必要的，但主要经验在临床决策中不可靠的立场在认识论上是不一致的。在这里，我们主张从主要经验中获得的知识对于医学实践的价值和效用。主要经验为诊断、治疗和评估个体患者的反应提供了必要的知识。当将证据层级作为临床决策的指导时，它们错误地混淆了命题知识和经验知识之间的关系。我们认为，主要经验代表了一种不同于临床研究产生的命题知识的医学知识，这两者对于确定特定患者的最佳诊断和治疗方案都至关重要。
