Knowledge Based Practice

Knowledge Based Practice (KBP)

The purpose of this blog started out to develop and articulate a system of thought for knowledge based practice. That process culminated with a launch of several related projects and sites - for more on that see the post.

Knowledge based practice is a clinical epistemology built on the foundations of critical realism. The purpose in articulating it is to help connect the empirical to the rationale to the practical, which then cycles back to the empirical (practice generates empirical observations whether they are systematically observed in a trial or not), the cycle continues. A knowledge based practice - as a “clinical worldview” - aims to turn the cycle described above into increasing knowledge over time. This can be considered on an individual basis (personal growth and development as a clinician) and on a meta level (knowledge growth of the profession). It is distinguished from evidence based practice in that it makes the rationale process of generating knowledge from observations a central component alleviating the need to translate evidence to knowledge. This stems from a recognition of the use of knowledge in the observations utilized to gather observations which become evidence and hence gives knowledge (a realist perspective of knowledge) central stage and priority. This is in opposition to evidence based practice which tends to give central stage and priority to an empirical  perspective of knowledge, which the blog attempts to demonstrate. To most these differences are subtle however I do believe they influence behavior and practice.

Clinical epistemology is a theory of how clinical knowledge is developed (see Definitions for a definition of epistemology). It is concerned with the place of experience and the place of reason in generating knowledge, that is to say the balance between experience (empirical observations, systematically collected or not) and reason (building models, theories, frameworks that identify causal connections and networks). It is also concerned with “concepts such as belief, certainty and the impossibility of error; and finally on the changing forms of knowledge that arise from new conceptualizations of the world.” (ODP - epistemology) The clinical epistemology being developed as part of this project is punctuated by its focus on causation (causality, causal models, causal networks) and its reliance on critical realism (particularly the balance of empirical and rationale knowledge, and the stratification of reality to avoid category mistakes).

Why a knowledge based practice

A reasonable question is why a knowledge based practice? Doesn’t evidence based practice imply a knowledge based practice? If evidence leads to knowledge, and knowledge leads to decisions, and decisions lead to practice then through transitivity aren’t we justified in just saying evidence based practice?

I used to think that way as well. But I have come to believe that something happens in the “Knowledge” area that prepares evidence for decisions and practice that cannot be skipped by transitivity. While evidence generates knowledge it does not do so automatically. There is a rationale model building process in the generation of knowledge that makes it fundamentally different from evidence. Evidence, an empirical set, is therefore related but different from knowledge, a rationale set. All aspects of “evidence based practice” such as empirical studies, relations, associations, risk of bias, hierarchy of evidence are all necessary components of evidence and knowledge based practice. But evidence is not sufficient for a knowledge based practice. This leads to the question: What else is required by knowledge for practice? This is a question I hope to unpack in the coming year through this blog.

As my colleagues and I develop a clinical practice guideline for PTs to use when working with patients that have heart failure I am reminded of the mass of assumptions between the published evidence and the actual decisions that need to be made by physical therapists in practice. What a clinical practice guideline is attempting to do is formulate knowledge from which to base practice, knowledge which includes a reasonable weight of evidence balanced with the assumptions surrounding that evidence and the existing set of knowledge. So a broader conceptualization of this process is that of clinical epistemology and knowledge based practice. For this process we need teams of clinicians and scholars to work together with a broader language than is currently utilized in evidence based practice.

Status Update - Where we are now in summary

This blog has attempted to establish that empiricism cannot be the only epistemological foundation for practice as it leads to skepticism. That a balance with the rationale, sort of in a Kantian manner but not a purely Kantian “critical” idealism, but rather a critical realism offers a more appropriate epistemological foundation for clinical practice. But then this requires us to reconsider the hierarchy used when generating that knowledge. If empiricism alone cannot generate the knowledge, then we should not look to empiricism alone to generate the knowledge. Expert opinion and consensus regarding empirical results thus start to be considered as ways to generate knowledge, but not completely, not disengaged from reality, but with critical reflection of the empirical reality.

For a chronological introduction from the start of the blog to April 27, 2015 - see my drafts page at here