The Reasoning of the Strongest: The Polemics of Skill and Science in Medical Diagnosis

Social Studies of Science

Volumn 22, Issue 4, 1992, Pages 653-684

  Anderson, Warwick ^a  

^a HARVARD UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

APPARATUS, EQUIPMENT AND SUPPLIES; ARTICLE; AUSTRALIA; DIAGNOSIS; HISTORY; HISTORY OF MEDICINE; HOSPITAL;

AUSTRALIA; DIAGNOSIS; EQUIPMENT AND SUPPLIES; HISTORY OF MEDICINE, MODERN; HOSPITALS;

EID: 0026955097     PISSN: 03063127     EISSN: 14603659     Source Type: Journal    
DOI: 10.1177/030631292022004005     Document Type: Article

References (111)

1. Ian R. Mackay, ‘Developments in Medical Science and Technology’, Postgraduate Medical Journal, Vol. 46 (1970), 182-90, at 182.
2. The most relevant early studies were: R.S. Ledley and L.E. Lusted, ‘Reasoning Foundations of Medical Diagnosis’, Science, Vol. 130 (3 July 1959), 9-21;
3. M. Lipkin et al. ‘Digital Computer as an Aid to Differential Diagnosis’, Archives of Internal Medicine, Vol. 108, No. 1 (July 1961), 56-72;
4. J.E. Overall and CM. Williams, ‘Conditional Probability Program for Diagnosis of Thyroid Function’, Journal of the American Medical Association [hereafter JAMA], Vol. 183 (2 February 1963), 307-13;
5. H.R. Warner, A.F. Toronto and L.G. Veasey, ‘Experience with Bayes’ Theorem for Comparative Diagnosis of Congenital Heart Disease’, Annals of the New York Academy of Sciences, Vol. 115 (July 1964), 558-67;
6. T.D. Sterling, J. Nickson and S.V. Pollack, ‘Is Medical Diagnosis a General Computer Problem?’, JAMA, Vol. 198 (17 October 1966), 281-86.
7. L.L. Weed, Automation of the Problem-Oriented Medical Record (Washington, DC: National Center for Health Services Research, 1977), 15. There are a number of reviews of the enterprise. Those of most relevance to the 1960s and 1970s are: R.A. Shegog, ‘Reviewing Some Applications of Computers to Medicine: A Tale of Two Philosophies’, in G. McLachlan (ed.), Problems and Progress in Medical Care (Oxford: Oxford University Press, 1968);
8. McLachlan and Shegog (eds), Computers in the Service of Medicine: Essays on Current Research and Applications (London: Oxford University Press, 1968);
9. W.B. Schwartz, ‘Medicine and the Computer: The Promise and Problems of Change’, New England Journal of Medicine [hereafter NEJM], Vol. 283 (3 December 1970), 1257-64;
10. S.J. Reiser, Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1978);
11. D.W. Young, - Survey of Decision Aids for Clinicians’, British Medical Journal [hereafter BMJ], Vol. 285 (6 November 1982), 1332-36;
12. and B.M. Kaplan, Computers and Medicine 1950-80: The Relationship between Policy and History (unpublished PhD dissertation, University of Chicago, 1983). On the more recent developments, see J.A. Reggia and S. Tuhrim, Computer-Assisted Medical Decision Making, 2 Vols (New York: Springer-Verlag, 1985);
13. Houziaux and P.J. Lefebre, ‘Historical and Methodological Aspects of Computer-Assisted Medical HistoryTaking, Medical Informatics (London), Vol 11 (1986), 129-43;
14. J.G. Anderson and S.J. Jay (eds), The Use and Impact of Computers in Clinical Medicine (New York: Springer-Verlag, 1987);
15. and Mike Pringle, ‘Using Computers to Take Histories’, BMJ, Vol. 297 (17 September 1988), 697-98.
16. T. Winograd, ‘Frame Representations and the Declarative/Procedural Controversy’, in D.G. Bobrow and A.M. Collins (eds), Representation and Understanding: Studies in Cognitive Science (New York: Academic Press, 1975), 185-210;
17. A.V. Cicourel, ‘The Reproduction of Objective Knowledge: Common Sense Reasoning in Medical Decision-Making’, in G. Bohme and N. Stehr (eds), The Knowledge Society: The Growing Impact of Scientific Knowledge on Social Relations (Dordrecht: Reidel, 1986), 87-122.
18. Eliot Freidson, Profession of Medicine: A Study of the Sociology of Applied Knowledge (NewYork: Dodd, Mead, 1970);
19. Anselm Strauss et al. Social Organization of Medical Work (Chicago, IL: The University of Chicago Press, 1985).
20. On the history of the disparate commitments of clinical scientists and ordinary physicians, see Joseph Ben-David, ‘Scientific Productivity and Academic Organization in Nineteenth-Century Medicine’, in B. Barber and W. Hirsch (eds), The Sociology of Science (New York: Free Press & London: Collier-Macmillan, 1962), 305-28;
21. R.C. Maulitz, ’ “Physician versus Bacteriologist” : The Ideology of Science in Clinical Medicine’, in M.J. Vogel and Charles Rosenberg (eds), The Therapeutic Revolution (Philadelphia, PA: University of Pennsylvania Press, 1979), 91-108;
22. S.E.D. Shortt, ‘Physicians, Science and Status: Issues in the Professionalization of Anglo-American Medicine in the Nineteenth Century’, Medical History, Vol. 27 (1983), 51-68;
23. David Armstrong, ‘Clinical Sense and Clinical Science’, Social Science and Medicine, Vol. 11 (1977), 599-601;
24. J.V. Pickstone et al. ‘Exploring Clinical Research: Academic Medicine and Clinicians in Early Twentieth-Century Britain’, Bulletin of the Society for the Social History of Medicine, Vol. 37 (1985), 79-8 L;
25. Christopher Lawrence, ‘Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 1850-1914’, Journal of Contemporary History, Vol. 20 (1985), 503-20;
26. Harry Marks, ‘Notes from the Underground: The Social Organization of Therapeutic Research’, in Russell Maulitz and Diana Long (eds), Grand Rounds: One Hundred Years of Internal Medicine (Philadelphia, PA: University of Pennsylvania Press, 1988), 299-338.
27. Judith Perolle, ‘Expert Enhancement and Replacement in Computerized Mental Labor’, Science, Technology, & Human Values, Vol. 16, No. 1 (Spring 1991), 195-207.
28. For ‘symmetry’, see David Bloor, Knowledge and Social Imagery (London: Routledge & Kegan Paul, 1976). My concern with orientations toward practice, investments in competences, the constructive activity of scientists and doctors, the inseparability of technical capacity and social power, and with exchange systems, owes much to the work of Pierre Bourdieu, especially his The Specificity of the Scientific Field and the Social Conditions for the Progress of Reason’, Social Science Information, Vol. 14 (1985), 19-47, and ‘The Peculiar History of Scientific Reason’, Sociological Forum, Vol. 6 (1991), 3-26.
29. Particularly Harry Collins, Artificial Experts: Social Knowledge and Intelligent Machines (Cambridge, MA: MIT Press, 1990). Many participants at the 1990 Bath Conference on ‘Rediscovering Skill in Science, Medicine and Technology’ seemed preoccupied with identifying the characteristics of skill, treating it as a self-evident non-transferable possession.
30. H.M. Collins, Changing Order: Replication and Induction in Scientific Practice (London & Beverly Hills, CA: Sage, 1985);
31. J.A. Schuster and Richard Yeo (eds), The Politics and Rhetoric of Scientific Method (Dordrecht: Reidel, 1986); see also Lucy Suchman, ‘Representing Practice in Cognitive Science’, in Michael Lynch and Steve Woolgar (eds), ‘Representation in Scientific Practice’, Special Issue, Human Studies, Vol. 11, Nos 2-3 (April/July 1988), 305-25, republished as Representation in Scientific Practice (Cambridge, MA: MIT Press, 1990), at 302-21.
32. See Collins, note 10. Collins emphasizes the social dimensions of even the most formal activities, and argues that behaviour cannot be explained by, or reduced to, explicit rules, unless our actions have (like production-line work) become machine-like, or unless we simply become more charitable to machines. In a sense, what I study here is a failed effort to encourage such charity. The diagnosis that scientists modelled is not a reduction of the diagnostic behaviour of physicians as much as an attempt to design a medical procedure that will be deemed to make sense as a diagnosis, given a restructured grammar of medical activities. I argue that all method talk - whether emphasizing formal rules or craft knowledge - is a social activity, and should be studied sociologically.
33. T.F. Gieryn, ‘Boundary-Work and the Demarcation of Science from Non-Science: Strains and Interests in the Professional Ideologies of Scientists’, American Sociological Review, Vol. 48 (1983), 781-95.
34. Bruno Latour, ‘Give Me a Laboratory and I Will Raise the World’, in Karin Knorr-Cetina and Michael Mulkay (eds), Science Observed: Perspectives in the Social Study of Science (London & Beverly Hills, CA: Sage, 1983), 141-70; Latour, Science in Action (Milton Keynes, Bucks.: Open University Press, 1987).
35. Michael Mulkay, Trevor Pinch and Malcolm Ashmore, ‘Colonizing the Mind: Dilemmas in the Application of Social Science’, Social Studies of Science, Vol. 17 (1987), 231-56.
36. For example, Latour (1983), note 14, recounts the relentless advance of bacteriology.
37. Alvan Feinstein, Clinical Judgement (Baltimore, MD: Williams & Wilkins, 1967), and his ‘An Additional Basic Science for Clinical Medicine: I. The Constraining Fundamental Paradigms’, Annals of Internal Medicine, Vol. 99 (1983), 393-97; ‘II. The Limitations of Randomized Trials’, 544-50;
38. Arthur Elstein, ‘Clinical Judgement, Psychological Research and Medical Practice’, Science, Vol. 194 (12 November 1976), 696-700.
39. Charles Bosk, Forgive and Remember (Chicago, IL: The University of Chicago Press, 1979);
40. Friedson, note 6; and D.R. Gordon, ‘Clinical Science and Clinical Expertise: Changing Boundaries between Art and Science in Medicine’, in M. Lock and Gordon (eds), Biomedicine Examined (Dordrecht: Kluwer, 1988), 257-98.
41. For similar arguments, see T.A. Parrino and R. Mitchell, diagnosis as a Skill: A Clinical Perspective’, Perspectives in Biology and Medicine, Vol. 33 (1989), 18-44. Medical diagnosis has frequently been used as an example of a skilful activity not amenable to logical-empiricist renderings: see, for example, Michael Polanyi, Personal Knowledge (London: Routledge & Kegan Paul, 1958);
42. H.L. Dreyfus and S.E. Dreyfus, Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer (New York: Free Press, 1986).
43. I was a medical student on the CRU ward in 1980, and an intern there in 1984.
44. L.L. Weed, ‘Medical Records that Guide and Teach’, NEJM, Vol. 278 (14 March 1968), 593-600.
45. D.W. Young, ‘What Makes Doctors Use Computers?: Discussion Paper’, Journal of the Royal Society of Medicine, Vol. 77 (August 1984), 663-67, at 664.
46. E. Freidson, Doctoring Together: A Study in Professional Social Control (New York: Elsevier, 1975), 167. On the history of the medical record, see S.J. Reiser, ‘Creating Form out of Mass: The Development of the Medical Record’, in E. Mendelsohn (ed.), Transformation and Tradition in the Sciences: Essays in Honor of LB. Cohen (Cambridge: Cambridge University Press, 1984), 303-16;
47. C.A. Nathanson and M.H. Becker, ‘Doctors, Nurses and Clinical Records’, Medical Care, Vol. 11 (1973), 214-23.
48. E. Mumford, Interns: From Students to Physicians (Cambridge, MA: Harvard University Press, 1970), 141.
49. More generally on this, see: Everett Hughes, ‘The Making of a Physician: General Statement of Ideas and Problems’, Human Organization, Vol. 14 (1956), 21-24;
50. Strauss et al. note 6; and Paul Atkinson, The Clinical Experience: The Construction and Reconstruction of Reality (Farnborough, Hants.: Gower, 1981).
51. The best account of clinical science in Melbourne, and of the Walter and Eliza Hall Institute (WEHI), is Macfarlane Burnet, Walter and Eliza Hall Institute 1915-1965 (Melbourne: Melbourne University Press, 1971); see also G.J.V. Nossal, Medical Science and Human Goals (Melbourne: Edward Arnold, 1975), and his ‘The Responsibilities of Scientists and Government for Research within a Medium-Sized Country’, in M. Bennett (ed.), Science and Society in Australia (Canberra: AAS, 1986), 95-100. V. deV. Davis, A History of the Walter and Eliza Hall Institute of Medical Research (unpublished PhD thesis, University of New South Wales, 1979) is useful, but concerned predominantly with Hall Institute administration.
52. Joint meeting of RMH and WEHI, Minutes (1 April 1946), 1.
53. Sir Ian Wood, Autobiography (Melbourne: Lothian, 1972).
54. Burnet, note 26, 78. Mackay had been a medical, student at RMH, but then worked in an Australian country hospital before obtaining a research position in Seattle. In Melbourne, with Carleton Gajdusek, he developed the autoimmune complement fixation test, and with Burnet he helped to define the new field of autoimmunity. Mackay wrote a number of important papers on chronic active hepatitis and SLE. With Burnet he wrote the classic Autoimmune Diseases: Pathogenesis, Chemistry and Therapy (Springfield, IL: Thomas, 1963). Burnet later won a Nobel Prize in Physiology and Medicine for his work on immunological tolerance.
55. See Hughes, note 25, for remarks on reference groups.
56. Interview with Professor R.R.H. Lovell, October 1987.1 was a medical student in Loveil's Department in 1981. Lovell discusses his ideas of clinical research in ‘The University Medical Presence in Hospitals Seventy Years after Flexner - and a Look Ahead’ [Stawell Oration 1982], Australian and New Zealand Journal of Medicine [hereafter ANZJM], Vol. 13 (1983), 187-94.
57. Interview with Dr Robert Fraser, July 1989.
58. Professor Priscilla Kincaid-Smith, in the Report of the Board of Medical Research of the RMH (Melbourne, 1987), 3.
59. Burnet, note 26, 76.
60. WEHI Annual Report (1965-66), 58.
61. F.M. Burnet, ‘Fifty Years On’, BMJ (1964), Vol. 2 (31 October), 1091-93, at 1092.
62. Weed, note 21; L.L. Weed, Medical Records, Medical Education and Patient Care: The Problem-Oriented Record as Basic Tool (Cleveland, OH: Case Western Reserve University Press, 1971). Lawrence Weed was a senior physician at Cleveland Metropolitan General Hospital, Western Reserve School of Medicine, in Ohio.
63. The best account of this is H.P. Lundsgaarde et al. Human Problems in Computerized Medicine (Lawrence, KA: University of Kansas Press, 1981); see also P.J. Fischer et al. ‘User Reaction to PROMIS: Issues Related to the Acceptability of Medical Innovations’, in Anderson & Jay (eds), note 3, 286-302.
64. Reiser, note 3, 202.
65. Lee Lusted, ‘Computer Techniques in Medical Diagnosis’, in R.W. Stacy and B.D. Waxman (eds), Computers in Biomedical Research, Vol. 1 (New York: Academic Press, 1965), 319-38.
66. T.A. McPherson and LR. Mackay, - Computer Project in Clinical Immunology’, Medical Journal of Australia [hereafter MJA] (1967), Vol. 1 (6 May), 924-27.
67. V.X. Gledhill, T.A. McPherson and I.R. Mackay, ‘The Application of Computers to Medical Records: A Computer System for the Storage and Retrieval of Medical Records’, Australasian Annals of Medicine, Vol. 19 (1970), 1-8, at 1.
68. WEHI Annual Record( 1966-67), 27. By 1968, Mackay was confident enough to tell a reporter that: ‘We see this system being fully established in every hospital in Victoria and then Australia wide, with the central data bank probably in Canberra. ‘: Lennard Bickel, ‘Computer will be Used for Diagnosis’, The Australian (11 March 1968).
69. J.D. Mathews, Morbidity: A Computational Approach (unpublished PhD dissertation, University of Melbourne, 1972). Mathews is the director of the Menzies Medical College, Darwin.
70. V.X. Gledhill, J.D. Mathews and I.R. Mackay, ‘Computers in the Service of Medicine’, MJA (1970), Vol. 2 (19 December), 1200-04, at 1202.
71. Nossal (1975), note 26, 165.
72. 166; interview with Sir Gustav Nossal, October 1987.
73. Gledhill, Mathews & Mackay, note 46.
74. Nossal (1975), note 26, 170.
75. WEHI Annual Report (1970-71), 56.
76. Bayes’ theorem states that the probability of any disease in a given patient depends on: (1) the prevalence of that disease in the population; (2) the finding of a particular symptom of that disease; and (3) the likelihood of the symptom being associated with that disease.
77. WEHI, note 51. Nossal reported to the WEHI Board that the test indicated that the computer ‘outshines physicians in diagnostic ability’: ‘Director's Bimonthly Report to the Board, 17 November 1969’, 5, WEHI Archives: 0010, ‘WEHI Board'.
78. D. Metcalf to E. Hughes-Jones, 29 April 1969, WEHI Archives: 0052, ‘CRU'.
79. D. Metcalf to C. Syme, 29 April 1969, WEHI Archives: 0010, ‘WEHI Board'.
80. I.O. Stahle, ‘Medicine at the Hospital’, RM H Quarterly (Autumn 1969), 18-19, at 19.
81. Interview with Professor R.R. Lovell, October 1987.
82. Sir A. Coates, ‘The Hospital over the Last 50 Years’, RMH Quarterly (Spring 1969), 13-15, at 13.
83. Nossal (1975), note 26,161. He continues: ‘The case memory of a given doctor is limited and fallible. The case memory of the computer is, in principle, virtually infinitely expandable, and certainly not susceptible to the sorts of errors that human memories exhibit’, 168. For another account of contemporary physician suspicions, see R.A. Thatcher, ‘The “Take-over Bid” by Computers in Medicine’, MJA (1969), Vol. 1 (14 June), 1258-59.
84. V.X. Gledhill, quoted in'Diagnosis by Machine’, The Age (18 November 1970).
85. Mathews, note 45, 1.
86. WEHI Annual Report (1968-69), 57.
87. 'Director's Bimonthly Report to the Board, 21 September 1970’, WEHI Archives: 0010, ‘WEHI Board'.
88. WEHI Annual Report (1976-77), 72.
89. WEHI Annual Report (1974-75), 86.
90. More generally on the CRU's work on narrative reports, see J.D. Buckley, ‘Narrative Report Generation from Numerically Coded Data’, Computers and Biomedical Research, Vol. 11 (1978), 525-36.
91. WEHI, note 67, 73.
92. Gledhill, Mathews & Mackay, note 46, 1202.
93. R.L. Teach and E.H. Shortliffe, ‘An Analysis of Physician Attitudes Regarding Computer-Based Clinical Consultation Systems’, in Anderson & Jay (eds), note 3, 80.
94. Interview with Dr I.R. Mackay, September 1987.
95. G. Nossal to W. Anderson, personal communication, 14 August 1991.
96. On another group who did not step lightly, see Mulkay, Pinch & Ashmore, note 15.
97. On this form of ‘closure’, see Everett Mendelsohn, ‘Political Anatomy of Controversy in the Sciences’, in H. Tristram Englehardt, Jr & Arthur L. Caplan (eds), Scientific Controversies (Cambridge: Cambridge University Press, 1987), 93-124. Also on methods of closure, or stabilization, see T. Pinch and W. Bijker, ‘The Social Construction of Facts and Artefacts, or How the Sociology of Science and the Sociology of Technology might Benefit Each Other’, Social Studies of Science, Vol. 14 (1984), 399-441, and Sharon Beder, ‘Controversy and Closure: Sydney's Beaches in Crisis’. Vol. 21 (1991), 223-56.
98. V. Gledhill and J. Mathews, ‘The Clinical Synopsis’, ANZJM, Vol. 2 (1974), 131-41.
99. V.X. Gledhill et al. ‘The Problem-Orientated Medical Synopsis’, Annals of Internal Medicine, Vol. 78 (1973), 685-91, at 690.
100. WEHI Annual Record (1971-72), 88.
101. Gledhill et al. note 77, 690.
102. Indeed, it could be argued that the physicians’ understanding of diagnosis is already undergoing a transformation as medical culture itself is altering. Much of the traditional medical diagnosis of ‘easy’ cases could be characterized as machine-like, to use Collins’ term, and the practitioner's craft knowledge is redundant - while diagnosis of'hard’ cases is frequently never resolved through the current procedures, in any case.
103. G. Nossal to W. Anderson, personal communication, 14 August 1991.
104. Indeed, they went as far as to suggest that patients might check their own records: D.P. Stevens, R. Stagg and LR. Mackay, ‘What Happens when Hospitalized Patients See Their Own Records’, Annals of Internal Medicine, Vol. 86, No. 4 (April 1977), 474-77. Of course, one of the striking features of this dispute is that neither group contesting the means of diagnosis seriously expected the opinions of patients to influence the debate.
105. For an illuminating discussion of approaches to the study of physician competence, see Mary-Jo D. Good, ‘Discourses on Physician Competence’, in R.A. Hahn and A.D. Gaines (eds), Physicians of Western Medicine: Anthropological Approaches to Theory and Practice (Dordrecht: Reidel, 1985), 247-67; Armstrong, note 7; Shortt, note 7; Lawrence, note 7.
106. Freidson, note 6.
107. Michael Lynch and Steve Woolgar, ‘Sociological Orientations to Representational Practice in Science’, in Lynch & Woolgar (eds), note 11 (1988), 99-116, at 110,(1990) 1-18, at 13.
108. Harold Garfinkel, Studies in Ethnomethodology (Englewood Cliffs, - J: Prentice-Hall, 1967), esp. 186-207. In particular, there is an interest in avoiding specifics in the record.
109. Mackay, note 1, 182.
110. Garfinkel, note 86, 200.
111. For another perspective on the lack of inevitability in the ‘scientification’ of skill, see Richard Whitley, ‘The Transformation of Expertise by New Knowledge: Contingencies and Limits to Skill Scientification’, Social Science Information, Vol. 27 (1988), 391-420.