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The limits of objective assessment of medical practice

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Abstract

Medical work is increasingly being subjected to objective assessment as those who pay for it seek to grasp the quality of that work and how best to improve it. While objective measures have a role in the assessment of health care, I argue that this role is currently overestimated and that no human practice such as medicine can be fully comprehended by objective assessment. I suggest that the character of practices, in which formalizations are combined with judgment, requires that valid assessment involve the perspective of the skilled practitioner. Relying exclusively on objective measures in assessing health care will not only distort our assessments of it but lead to damage as the incentives of health care workers are directed away from the important aspects of their work that are not captured by objective measures.

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Notes

  1. Accreditation Council for Graduate Medical Education [3] (2001, http://www.acgme.org/acWebsite/home/home.asp). Accessed 5/17/07.

  2. An illustration owed to Cussins [4].

  3. The capsule account of practices offered here is not uncontroversial but is broadly consistent with the views of philosophers, educators, and sociologists who have been influenced by Wittgenstein. See, for instance, Stroud [5], Hanna and Harrison [6] and Schatzki [7].

  4. The distinction between formalization and judgment made here is similar to that drawn by Nelson [8]. The ensuing discussion also draws upon the considerable literature on Wittgenstein and rule-following, particularly the work of John McDowell. See, for instance, McDowell [9].

  5. In regard to perception conceived as an achievement, see Noe [10].

  6. This is of course a controversial claim. The world exists apart from our concepts but we necessarily apprehend it through them. The dominant tradition in linguistics and analytic philosophy views this apprehension as mediated primarily through representations; we form concepts that mirror the world and hence achieve a cognitive grasp of it—thus “referential realism” (to use Hanna and Harrison’s term; see footnote 3) in theories of meaning and representation theories of mind in philosophy of mind. I follow here an opposing tradition, upheld in continental philosophy and by a minority of analytic philosophers influenced by Wittgenstein who reject the primacy of representations in favor of some variant of “knowing how”—knowing how to act in a social practice for Wittgenstein and his successors, “embodied coping” for Hubert Dreyfus, “sensorimotor knowledge” in the work of Alva Noë, “motor intentionality” for Merleau-Ponty. As Charles Taylor contends, “our grasp of things is not something that is in us, over against the world; it lies in the way we are in contact with the world, in our being-in-the-world....” [11]. See also Haugeland [12], Devitt [13], Dreyfus [14], Hanna and Harrison and Stroud as cited in footnote 3, above.

  7. I owe this illustration to Nelson, “Unlike Calculating Rules.”

  8. This line of objection to the ACGME’s approach to assessing competence in medical trainees is developed further in Huddle and Heudebert [15].

  9. CMS Office of Public Affairs [20]. Press Release, Center for Medicare and Medicaid Services Website, http://www.cms.hhs.gov/apps/media/press_releases.asp. Accessed 18 May 2007.

  10. A point forcefully made by O’Neill [21].

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Acknowledgments

I would like to thank Robert M. Centor for helpful comments on earlier versions of this article and the editor of TMBE for useful suggestions.

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Authors and Affiliations

  1. Division of General Internal Medicine, University of Alabama at Birmingham School of Medicine, 1530 3rd Avenue South, FOT 720, Birmingham, AL, 35294, USA

    Thomas S. Huddle

  2. The Birmingham VA Medical Center, Birmingham, AL, USA

    Thomas S. Huddle

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Correspondence to Thomas S. Huddle.

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Huddle, T.S. The limits of objective assessment of medical practice. Theor Med Bioeth 28, 487–496 (2007). https://doi.org/10.1007/s11017-007-9054-9

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