Skip to main content
PMC home page
The Yale Journal of Biology and Medicine logoLink to The Yale Journal of Biology and Medicine
. 1990 Jan-Feb;63(1):47–61.

The tacit dimension of clinical judgment.

G M Goldman 1
PMCID: PMC2589248  PMID: 2356625

Abstract

Two distinct views of the nature of clinical judgment are identified and contrasted. The dominant view that clinical judgment is a fully explicit process is compared to the relatively neglected view that tacit knowledge plays a substantial role in the clinician's mental operations. The tacit dimension of medical thinking is explored at length. The discussion suggests severe limits when applying decision analysis, expert systems, and computer-aided cost-benefit review to medicine. The goals and practices of postgraduate medical education are also examined from this perspective, as are various other implications for the clinician. The paper concludes that it is valuable to explore the nature of medical thinking in order to improve clinical practice and education. Such explorations should, however, take cognizance of the often overlooked tacit dimension of clinical judgment. Possible constraints on the medical applicability of both formal expert systems and heavily didactic instructional programs are considered.

Full text

PDF

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bergman D. A., Pantell R. H. The art and science of medical decision making. J Pediatr. 1984 May;104(5):649–656. doi: 10.1016/s0022-3476(84)80938-5. [DOI] [PubMed] [Google Scholar]
  2. Eddy D. M. Clinical policies and the quality of clinical practice. N Engl J Med. 1982 Aug 5;307(6):343–347. doi: 10.1056/NEJM198208053070604. [DOI] [PubMed] [Google Scholar]
  3. Elstein A. S. Clinical judgment: psychological research and medical practice. Science. 1976 Nov 12;194(4266):696–700. doi: 10.1126/science.982034. [DOI] [PubMed] [Google Scholar]
  4. Feinstein A. R. Clinical biostatistics. XXXIX. The haze of Bayes, the aerial palaces of decision analysis, and the computerized Ouija board. Clin Pharmacol Ther. 1977 Apr;21(4):482–496. doi: 10.1002/cpt1977214482. [DOI] [PubMed] [Google Scholar]
  5. Harris J. M., Jr The hazards of bedside Bayes. JAMA. 1981 Dec 4;246(22):2602–2605. [PubMed] [Google Scholar]
  6. Hopkins J. A., Shoemaker W. C., Greenfield S., Chang P. C., McAuliffe T., Sproat R. W. Treatment of surgical emergencies with and without an algorithm. Arch Surg. 1980 Jun;115(6):745–750. doi: 10.1001/archsurg.1980.01380060043011. [DOI] [PubMed] [Google Scholar]
  7. Howe K. R., Holmes M., Elstein A. S. Teaching clinical decision making. J Med Philos. 1984 May;9(2):215–228. doi: 10.1093/jmp/9.2.215. [DOI] [PubMed] [Google Scholar]
  8. Kassirer J. P. Adding insult to injury. Usurping patients' prerogatives. N Engl J Med. 1983 Apr 14;308(15):898–901. doi: 10.1056/NEJM198304143081511. [DOI] [PubMed] [Google Scholar]
  9. Kassirer J. P. The principles of clinical decision making: an introduction to decision analysis. Yale J Biol Med. 1976 May;49(2):149–164. [PMC free article] [PubMed] [Google Scholar]
  10. Komaroff A. L. Algorithms and the "art' of medicine. Am J Public Health. 1982 Jan;72(1):10–12. doi: 10.2105/ajph.72.1.10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Munson R. Why medicine cannot be a science. J Med Philos. 1981 May;6(2):183–208. doi: 10.1093/jmp/6.2.183. [DOI] [PubMed] [Google Scholar]
  12. Pauker S. G., Kassirer J. P. Decision analysis. N Engl J Med. 1987 Jan 29;316(5):250–258. doi: 10.1056/NEJM198701293160505. [DOI] [PubMed] [Google Scholar]
  13. Politser P. E. Heuristics, normative models, and the value of serial test patterns. Behav Sci. 1986 Oct;31(4):260–277. doi: 10.1002/bs.3830310406. [DOI] [PubMed] [Google Scholar]
  14. Ransohoff D. F., Feinstein A. R. Editorial: Is decision analysis useful in clinical medicine? Yale J Biol Med. 1976 May;49(2):165–168. [PMC free article] [PubMed] [Google Scholar]
  15. Schwartz W. B., Gorry G. A., Kassirer J. P., Essig A. Decision analysis and clinical judgment. Am J Med. 1973 Oct;55(3):459–472. doi: 10.1016/0002-9343(73)90203-9. [DOI] [PubMed] [Google Scholar]
  16. Schwartz W. B. Sounding board. Decision Analysis: a look at the chief complaints. N Engl J Med. 1979 Mar 8;300(10):556–559. doi: 10.1056/NEJM197903083001011. [DOI] [PubMed] [Google Scholar]
  17. Wasson J. H., Sox H. C., Neff R. K., Goldman L. Clinical prediction rules. Applications and methodological standards. N Engl J Med. 1985 Sep 26;313(13):793–799. doi: 10.1056/NEJM198509263131306. [DOI] [PubMed] [Google Scholar]
  18. Zarin D. A., Pauker S. G. Decision analysis as a basis for medical decision making: the tree of hippocrates. J Med Philos. 1984 May;9(2):181–213. doi: 10.1093/jmp/9.2.181. [DOI] [PubMed] [Google Scholar]

Articles from The Yale Journal of Biology and Medicine are provided here courtesy of Yale Journal of Biology and Medicine

RESOURCES