Pause, reflect, continue….

Just a moment to pause and reflect a bit more on the comment made by Nate (DPT student - see his comment and my response in the “Models” post) prior to launching into posts about inference. I want to expand on my response, with what I mean by a “both / and” as opposed to “either / or” approach to “empiricism” and “rationalism.”

I woke up with a more clear way to explain what I hope a knowledge based practice offers to the discussion, based on Nate’s example. This is not a foundation that will distinguish KBP as a system of thought about practice. But it follows from its foundation. I believe this is part of EBP, and it is even communicated as part of EBD, it just sometimes gets lost within the dialogue due to the depth of our empirical frame of reference. I am often surprised when following a stream of thought to find how deep in the empirical forest I exist. A fish does not realize it is wet unless taken out of water, and even then, what concept of dry does it have?

In Nate’s example we hear about a systematic review providing empirical evidence; and then a case that does not quite fit the characteristics and evidence in the systematic review. But due to the “clinician’s dilemma” as I refer to it (any action, including no action, reflects a decision and therefore once you start engaging with a patient you are making clinical decisions), the therapist makes decisions. These decisions are “knowledge based.” And it is pragmatism (Peirce’s conception of pragmatism) that helps in making these decisions. However, this does not reflect an “either evidence; or knowledge” decision. Keep in mind that the empirical evidence in the systematic review will contribute to the knowledge (causal models, etc) that the therapist applies even if not directly applicable because of the generalizability of the causal relations (in terms of inference these generalizable causal relations form our premises). The systematic review contributes to the knowledge, and then used when treating the case through some of the premises invoked in the causal inferences utilized, so we have a “both evidence, and knowledge” decision.

It is a misunderstanding to assume that we can ever directly apply results from any study or systematic review to a case as if by direct transfer. Studies report sample statistics, systematic reviews report samples of sample statistics. There is always a generalization of these results into general premises about causal relations that are then specifically applied as appropriate, competing with a host of other premises. I believe that is a misunderstanding sometimes promulgated by evidence based practice, that a knowledge based practice attempts to rectify (as a side benefit, not as its primary objective). Of course, while ironic, I have no evidence.

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