Knowing in medical practice: expertise, imaging technologies and interdisciplinarity

This dissertation deals with knowing in medical practice by focusing on what epistemic agents such scientists, engineers, and medical professionals do when they construct and use knowledge, and what criteria play a role in evaluating the results. Based on experiences as a student and researcher in Technical Medicine, I have learned that current ideas about decision-making in clinical practice – i.e., the epistemology of evidence-based medicine (EBM) – are limited. Instead of deferring (a part of) their responsibility to clinical guidelines, doctors have epistemological responsibility for their clinical decisions. This means that they are responsible for the collection, critical appraisal, interpretation and fitting together of heterogeneous sources of evidence into a ‘picture’ of the patient. Understanding how the epistemological responsibility of doctors can be developed and how it can be assessed requires a more detailed account of (medical) expertise. I argue that this involves an account of the epistemic activities that clinicians should be able to perform and the cognitive skills that allow them to perform these activities. An account of expertise also improves our understanding of interdisciplinary research projects. Through their training, experts develop a disciplinary perspective that shapes how they deal with a target system. In interdisciplinary research aimed at problems in medical practices, multidisciplinary teams consisting of disciplinary experts interact around a problem, each exercising their own disciplinary perspective in dealing with aspects of the target system, rather than integrating theories. An important example of such an interdisciplinary research project is the development of a new medical imaging technology. Medical images do not speak for themselves but need to be interpreted. For this, engineers and clinicians need to enter into a shared search process to establish what an image represents, which requires an understanding of medical practice to establish for what relevant clinical claims they might provide evidence, whereas an understanding of the imaging technology is required to establish the reliability of this evidence. In medical practice, interdisciplinary collaborations are also important. Knowing in current medical practice is distributed over professionals with different expertises who collaborate in the construction of clinical knowledge. This collaborative character of epistemic practices in clinical decision-making leads to complex social practices of trust. Trust in these practices is implicit, in the sense that trusting the expertise of others occurs while the members of a team focus on other tasks, most importantly, building up a framework of common ways of identifying and assessing evidence. It is within this intersubjective framework that trusting or mistrusting becomes meaningful in multidisciplinary clinical teams.