What's Your Epistemology? Think About It - STFM

356 May 2009 Family Medicine
Essays and Commentaries
What’s Your Epistemology? Think About It
Roland M. Grad, MDCM, MSc
One word I never heard when training
to be a physician was epistemology,
a branch of philosophy concerned
with the nature of knowing.
Epistemology primarily addresses
the following questions: “How is
knowledge acquired?” “What do
people know?” and “How do we
know what we know?” Of course,
I studied the practice of medicine,
not the history and philosophy of
science. Yet epistemology is increasingly
on my radar screen, in
part due to an article in this issue
of Family Medicine that relates
physicians’ epistemology to their
reactions to uncertainty. 1
Epistemology and Uncertainty
As family physicians, we routinely
confront uncertainty, ambiguity,
and complexity. Our literature
devotes a great deal of
attention to uncertainty, with the
goal of helping patients and physicians
confront it. 2 Yet, when was
the last time you thought about how
your emotions influenced decisions
made in response to diagnostic or
therapeutic uncertainty?
In their cross-sectional survey
of primary care physicians, Evans
and Trotter report an intriguing
relationship between physicians’
(Fam Med 2009;41(5):356-7)
See related article on pages 319-26.
From the Department of Family Medicine,
McGill University.
epistemology and their reactions to
uncertainty. Using the Physicians’
Belief Scale to measure physicians’
epistemology, they found a biopsychosocial
epistemology to be associated
with less stress in reaction
to uncertainty. A biomedical epistemology,
on the other hand, was
associated with more stress in reaction
to uncertainty. This means that
in medical encounters, emotional
reactions to uncertainty, and by
extrapolation our clinical decisions,
are influenced by how we respond
to mind-body relationships. Thus,
we are asked to consider how our
epistemological commitment influences
our affective and behavioral
reactions to uncertainty.
For clinical teachers, what is the
relevance of the findings reported
by Evans and Trotter? For one,
think about how we interpret the
propensity of some trainees to
systematically “over” or “under”
investigate when patients present
with nonspecific somatic complaints,
such as chronic fatigue.
For another, the authors rightly
draw attention to the role of stress
reactions to uncertainty, which
stimulates medical testing and its
associated risk. Let me elaborate
further by examining how I view
my epistemology and how I cope
with uncertainty in clinical decision
making.
My Epistemology
As family physicians, our work
demands an approach that is neither
like that of the vascular surgeon
(highly biomedical) nor that of the
psychotherapist (highly biopsychosocial).
As such, my epistemology
lies somewhere between these two
extremes and may vary according
to the context of my patients and
their illnesses. Personally, I have
an interest in using research-based
information to improve my patient
care; seeking some measure of
comfort in scientific knowledge,
I trained in evidence-based medicine,
clinical epidemiology, and
biostatistics. Working in an academic
setting, I am also constantly
asked questions by students and
challenged to revisit my clinical decisions.
Faced with the impossible
task of appraising new researchbased
information on my own, I use
shortcuts and read the secondary
literature of pre-appraised synopses.
In other words, I search for
answers to my clinical questions,
retrieve the “best” evidence, and
apply it in practice. This is a very
biomedical epistemology, but it has
limits.
As an example, I offer the following
simple case. During a routine
check-up, a mother showed me her
child’s wart. The small stubborn
wart was not responding to salicylic
acid treatment. At that moment, I
recalled reading a synopsis about
a randomized trial of duct tape,
which showed it was a reasonable
alternative to cryotherapy. A few
quick taps on my PDA screen allowed
me to retrieve a synopsis
of the study, which the patient’s
mother and I read to know exactly
what to do. Of course, just a few
months later, I came across another

Essays and Commentaries
Vol. 41, No. 5
357
trial of duct tape for treating warts
in children. In this better designed
trial, duct tape was no more effective
than corn pads (a placebo). In
retrospect, the limits of relying on
single studies with a relatively low
level of evidence should have been
apparent. But in the moment of decision
making, these methodological
limitations were ignored.
My duct tape story is meant to illustrate
the limitations of a biomedical
epistemology. It is not unusual
for the initial results of clinical
research to be subsequently contradicted,
and even the most highly
cited randomized controlled trials
may be challenged and refuted over
time. 3 While EBM fits easily within
the classical biomedical model, I
now more clearly recognize the
limitations of this approach.
An In-between Epistemology
Of course, many patients in
primary care require a more biopsychosocial
approach. As such, in
my clinical practice I often go back
and forth between a biomedical and
biopsychosocial epistemology.
Similarly, in my research, I am
neither purely quantitative nor
qualitative. I have adopted a mixed
methods approach. 4-8 The division
of methods within health sciences
as qualitative or quantitative has
its roots in the different “world
views” of constructivism and logical
empiricism, which are usually
presented as competing paradigms.
Constructivism is associated with
idealism, relativism, and subjectivity,
while logical empiricism is associated
with materialism, realism,
and objectivity. Constructivism is
most frequently associated with
inductive qualitative studies and
logical empiricism with deductive
quantitative studies. Mixed methods
may be conceived as methods
that loop between constructivism
and logical empiricism and include
the notion that something can be
“both socially constructed and yet
real”. 9
Why Bother With Epistemology
and Uncertainty in Medical
Decision Making?
If I am neither like a highly
biomedical vascular surgeon or a
highly biopsychosocial psychotherapist,
then one limitation of
the paper by Evans and Trotter
needs to be made explicit. That is,
a physician’s epistemology may
be flexible, moving back and forth
depending on the context of our
clinical encounters.
If we are unaware of our epistemology
or how it influences clinical
practice, then what benefits would
such awareness bring? To what
extent does experience or maturation
lead to a change or shift in
epistemology? Any temptation you
may have to systematically administer
the Physicians’ Belief Scale to
trainees with whom you interact
should be tempered by the consideration
that these are research
questions, not yet answered.
In the meantime, one strategy
for clinical teaching might be to
acknowledge the limits of our
knowledge base. Knowing that uncertainty
may generate more stress
for some trainees than for others,
depending on epistemology, we can
encourage our trainees to search
for answers to clinical questions
and promote discussion around
the valid type of uncertainty that
comes from increasing experience
and awareness of our limits.
Acknowledgments: I thank both Pierre Pluye and
Michael Malus for their contributions.
Correspondence: Address correspondence to Dr
Grad, Herzl Family Practice Centre, 3755 Cote
Ste Catherine Road, Montreal, Quebec H3T 1E2.
514-340-8222, ext. 5851. Fax: 514-340-8300.
roland.grad@mcgill.ca.
Re f e r e n c e s
1. Evans L, Trotter DRM. Epistemology and
uncertainty in primary care: an exploratory
study. Fam Med 2009;41(5);319-26.
2. Bursztajn HJ, Feinbloom RI, Hamm R, Brodsky
A. Medical choices, medical chances:
how patients, families, and physicians can
cope with uncertainty. New York: Routledge,
Chapman and Hall, Inc, 1990.
3. Ioannidis JPA. Contradicted and initially
stronger effects in highly cited clinical research.
JAMA 2005;294(2):218-28.
4. Pluye P, Grad RM, Levine A, Nicolau B. Divergence
of quantitative and qualitative data
or results: four strategies and an exercise for
novice mixed methods researchers. Journal
of Multiple Research Approaches 2009, in
press.
5. Creswell JW, Plano-Clark VL. Designing
and conducting mixed methods research.
Thousand Oaks, Calif: Sage, 2007.
6. Greene JC. Mixed methods in social inquiry.
San Francisco: Jossey-Bass, 2007.
7. Johnson RB, Onwuegbuzie AJ, Turner LA.
Toward a definition of mixed methods research.
Journal of Mixed Methods Research
2007;1(2):112-33.
8. Tashakkori A, Teddlie C. Handbook of mixed
methods in social and behavioral research.
Thousand Oaks, Calif: Sage, 2003.
9. Hacking I. The social construction of what?
Cambridge: Harvard University Press,
1999.