Clinical judgement, expertise and skilled coping

Medicine involves specific practical expertise as well as more general context-independent medical knowledge. This raises the question, what is the nature of the expertise involved? Is there a model of clinical judgement or understanding that can accommodate both elements? This paper begins with a summary of a published account of the kinds of situation-specific skill found in anaesthesia. It authors claim that such skills are often neglected because of a prejudice in favour of the 'technical rationality' exemplified in evidence-based medicine but they do not themselves offer a general account of the relation of practical expertise and general medical knowledge. The philosopher Hubert Dreyfus provides one model of the relation of general knowledge to situation-specific skilled coping. He claims that the former logically depends on the latter and provides two arguments, which I articulate in the second section, for this. But he mars those arguments by building in the further assumption that such situation-specific responses must be understood as concept-free and thus mindless. That assumption is held in place by three arguments all of which I criticize in the next section to give a unified account of clinical judgement as both practical and conceptually structured and thus justified in the face of a prejudice in favour of 'technical rationality'.