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J Higgs, B Richardson, M A Dahlgren. Oxford: Butterworth-Heinemann, 2004. £25.00. 240 pp. ISBN 0 70506 5429 5
To offer up a challenge to traditional approaches of knowledge and clinical practice is not new. Indeed, the birth of evidence based medicine/evidence based practice (EBM/EBP) in the 1990s was hailed as providing an overdue and welcome challenge to the poor justification underpinning much clinical care. However, EBM/EBP has also been criticised by some as fostering a misguided and reductionist notion of what comprises “evidence”. Others have gone so far as to suggest that EBM and EBP are signs of managerialism gone mad, being simply a malevolent attempt to control expenditure in a cash strapped system. Whilst it might be tempting to view this book as offering up similar fare, Higgs et al very eloquently discuss a wide range of complicated issues involved in debates about the nature of health professional practice knowledge and evidence.
The central thrust of the various chapters of the book is the argument that “how practice knowledge is created, used and further developed” needs to be considered more explicitly within professional practice. The editors suggest we need to establish a different and more appropriate way of thinking about knowledge, a “practice epistemology”. Some readers may be put off by the use of such terms before even the preface is finished, but perseverance is rewarded.
Contributors are largely allied health professionals from a range of backgrounds including physiotherapy, nursing, and behavioural sciences. Each chapter comprehensively tackles core issues in the debate about the creation and transfer of knowledge into practice. The book is more theoretical than practical, but it does discuss the very real issues that emerge where intervention processes and outcomes are complex and arguably less amenable to randomised controlled trials than specific drug or surgical interventions. As to whether randomised controlled trials are less “do-able” in certain areas of practice probably depends on where you sit on the continuum of the construction of knowledge. Suffice to say—there is little fence sitting in this book.
The authors are unapologetic about suggesting that the positivist approach inherent in much clinical research has left some of the biggest questions about practice knowledge unanswered. This perspective means that the book will no doubt be popular amongst the already converted, but the debate is intelligent and should be of interest to any “thinking” health professional looking at improving their practice and being clear on the rationale for doing so. Insightful comments abound, and the book provides a stimulating challenge to some well held assumptions and beliefs about what underpins practice and what “best evidence” really is.
Unthinking adherence to any rigid approach to knowledge is unlikely to prove rewarding to either health professionals or their patients. For those who want to question their practice and their understanding of evidence, this book is a thought provoking and challenging read.