Based on the professional experience, totalling 150 years, of three public health physicians and that of a general practitioner each of whom have combined practical and academic background, we (the authors) justify the epistemological integration of clinical and public health medicine while discussing the necessity for social / professional ethics and the need for hybrid, clinical / public health decisions and action in medical practice. After exploring the hybrid nature of key medical responsibilities, we examine the related knowledge and determine how joint practice should be delivered, managed, and researched professionally, i.e., by people with particular skills and qualifications, sufficient autonomy, and abiding by professional ethics [14]. We revisit the epistemological border of clinical and public health knowledge to support joint practice. From action-research and cognitive psychology, we derive medical knowledge categories that require different transmission and discovery techniques, to support professionally- and socially-oriented medical practice and management. We analyse the difference between proposed neo-Hippocratic medicine and management, and the industrial, ‘generic’ management applied to healthcare. The essay is supported by a Pubmed bibliographic search with the terms ‘physicians public health knowledge needs’ (2000–2020).
How should medical (and health) professions evolve to encompass cross-responsibilities of clinicians and public health practitioners in order to improve the quality and accessibility of individual care and disease control?
Public health activities in clinical practice
Consider first-line clinicians, general practitioners (GPs), or paediatricians. They have practical and conceptual public health responsibilities, as follows:
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In principle, physicians should combine (possibly programmed) primary, secondary, and tertiary prevention, curative care, and health promotion and tailor this mixture to the individual, family, and/or community.
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The family physician should practice community medicine – for example, to manage drug addiction or violence at home.
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To the extent that GPs must practice community medicine and deliver preventive care, they should accept responsibility for the whole community or geographic areas (territories) healthcare needs.
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Doctors should know how to avoid ‘patient’s delay’ (for example in women with a placenta praevia) and ‘doctor’s delay’ (for example in detecting TB); reduce transmission (of HIV, for example); secure continuity of care for patients; and provide longitudinal care for each type of disease.
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Good practice requires adjusting clinical protocols to local epidemiology because human resources, medical technology, or pharmaceuticals may not be available; and because disease frequency may vary significantly from neighbourhood to neighbourhood and therefore also the predictive value of signs, symptoms and test results.
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Medical practice requires the ability to read and interpret scientific, medical and policy evidence critically [15] and to do so not only from the standpoint of clinical epidemiology, [16] but also in the light of sociological and political economy concepts.
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Physicians should improve the way their health care services are organised (e.g. with regard to access to care, knowledge management, clinical coordination, reflection, doctors’ intangible motivation and health information) and shape the organisation in a way that is conducive to quality care. For example, GPs can pre-arrange communication channels with specialists to share decisions based on the patient’s health and family circumstances.
Although this list is not exhaustive, the clinical responsibilities of general practitioners not only demand their familiarity with public health concepts such as (clinical) epidemiology, disease control and health management but also the integration of clinical and public health knowledge. The correct care of the patient supposes not only curative but also preventive activities, and action on his/her environment. This similarly applies to the public health knowledge of hospital specialists because, they should also be able to deliver bio-psychosocial care, participate in the way that the health system is organised, and be involved in the organised control of diseases (e.g. nosocomial infections) and in the adjustment of patients’ average length of stay (in dialogue with their patient’s GP).
Individual care delivery in public health programmes
Public health practitioners, for their part, should include elements of individual health care delivery in their collective health practices and mobilise clinical knowledge out of concerns for community health, in order to improve disease control programmes:
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Preventive care and health education should be tailored to individual biopsychosocial risks and demands for care, and public health interventions cannot simply be treated as a mass activity. Well-baby, antenatal, geriatric and HIV/AIDS clinics are examples of this. While risks and sometimes pathologies are multiple, the goal-oriented approach of medical practice encourages and assists individuals to achieve their maximal health potential in line with individually defined goals [17]. This approach should thus drive public health doctors to shift from chronic disease management to participatory patient management [18].
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Effective prevention requires proper treatment of inter-current episodes of illness, with consequences for the accessibility of medical care by high-risk patients and subsequently for clinical coordination.
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Disease control programmes are best carried out if epidemiologists can interpret the paradoxical results of (nosocomial, HIV, measles, etc.) surveillance and are able to give sound clinical advice and sustain a dialogue with clinicians (which is why physicians make good epidemiologists).
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Disease control programmes may crowd out individual care, with, for example, a ‘one size fits-all’ approach and a bureaucratic load that strains the quality of care [8]. This produces a Catch 22 situation in which disease control is undermined when, as is frequently the case, the relevant (diabetes, malaria, tuberculosis, etc.) control programme relies on appropriate clinical activity in first-line services to deliver its interventions [19]. There is increasing evidence that accessible, good, quality community-based clinical care provides the necessary confidence for public health interventions to be acceptable to the population. Public health programmes need to be organised in such a way that protects, rather than undermines, access to and the quality of, individual health care and clinical practice.
These responsibilities justify the need for public health physicians to be well informed about topical clinical procedures, interpersonal communication, and philosophy, as well as mastering the relevant behavioural skills.
At the highest level of integration, medical officers (senior government officials who are put in charge of medical services in order to advise and lead teams of medical experts in charge of local health systems or hospitals) should integrate completely joint clinical/public health practices. Their responsibility, however, may be thwarted by a debilitating lack of resources (two or three physicians for a population of 200,000 in some rural and suburban Sub-Saharan Africa, for instance).
Consequences for health knowledge
Medical professionalism and specifically joint clinical/public health practice have implications for medical knowledge, health management, research, and medical education:
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The design and implementation of public health interventions should build on locally available medical knowledge and mores, for example, to adapt disease control guidelines to local conditions.
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Both public health doctors and clinicians should continuously and critically read professional literature respectively drawn from clinical medicine and public health. Accessing and using relevant knowledge from other fields of activity is an often neglected challenge.
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Although eco-biopsychosocial care ideally entails inter-professional teams, some personal, internalised integration of public health and clinical knowledge is required because GPs and family doctors must combine curative and preventive care (see above); tailor this mix to each patient; and negotiate therapy, life -style advice, and the use of medical services with the patient (the person-centred care standard).
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If GPs and specialists are expected to set quality of care criteria and therapeutic objectives together (a must when the patient is hospitalised), health systems also need to manage GPs and specialists’ knowledge in such a way that lets the two groups communicate effectively.
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Academia should be in a position to attract physicians capable of conceptualising and transmitting their experience. However, academic circles are increasingly off limits to clinical and public health practitioners because experience and professionalism, as opposed to bibliometrics, are not easily evaluated, and academic salaries may present opportunity costs to physicians.
Joint clinical / public health medical practice, a professional endeavour
According to Barondess, [20] ‘Professions are complex social structures derived from the guild system of specialised competences intended to organise specialised and complex bodies of knowledge in such a way as to address both individual and societal needs. These are the basis of a social contract enfranchising the members of a profession. It makes professional knowledge central to the well-being of today’s society.’
Integrated clinical/public health knowledge is professional in principle because joint clinical/public health practice is a professional endeavour. Indeed, medical practice has evaded standardisation in several domains, as evidenced by the following examples:
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Clinical decisions [21] - because evidence-based medicine has been strained through misappropriation by vested interests, inflexible rules, technology-driven initiatives, and an unmanageable volume of information [22];
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Eco-biopsychosocial care delivery [23, 24] and professional education – because both build upon emotional intelligence (the ability to understand your emotions and those of other people and to behave appropriately in different situations) [25] and communication skills;
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The treatment of multi-pathologies and a goal-oriented clinical approach [26] – since this entails doctor patient negotiation;
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Surgery, radiotherapy and gynaecology – because they require manual skills;
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The physician’s commitment to community health [27] – because public health programmes should be negotiated with at-risk patients in the same way that clinical options should be discussed between the doctor and the patient.
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The ethical nature of clinical decisions – because the motivation that drives medical professionals is intangible [28, 29].
Clinical and public health doctors both need adequate professional autonomy because the quality of care depends on the physician’s professionalism. Similarly, physicians in managerial positions need sufficient autonomy to promote professionalism and ethics in health care services.
Knowledge gaps in joint clinical and public health practice
Historically, clinical practice and science benefited from the public health science which has delivered a large body of concepts and quantitative inputs. To name just a few such inputs,
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Clinical epidemiology and evidence-based medicine (EBM) provided treatment guidelines;
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Epidemiology informed the design of prevention and health promotion interventions in curative care practice;
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The surveillance of nosocomial infections shaped antibiotic therapy in hospitals;
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Pharmaceutical evaluations built upon and enlarged (clinical) epidemiology methodology; and
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Health management science addressed medical communication and coordination.
However, public health science could have served care much better if it had not produced exclusively normative knowledge, knowledge geared towards decision-making, principally (only?) when public health and clinical epidemiology norms and recommendations were grounded in quantitative, probabilistic research. Indeed, in general it has only contributed to doctors’ and managers’ decision-making when the underlying rationale was quantifiable, for example, based on morbidity and mortality statistics; on the predictive value of signs, symptoms, and test results; or on the effectiveness and cost of interventions.
An examination of joint clinical/public health practice reveals knowledge gaps in both fields. Tasche et al. ([30], cited by De Maeseneer, [31]) analysed 70 guidelines issued by the Dutch College of GPs and identified 875 relevant clinical questions with no answer in published work.
In many countries, most physicians lack insights into:
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The management of professional organisations, for example, how to organise teamwork, to improve clinical coordination, and to lead action-research;
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Reflective methods used to improve medical practice and service delivery; and
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Techniques able to (de-)centralise medical technologies away from hospitals into first-line services and also, the reverse, in order to improve accessibility and efficiency of care.
Similarly, public health science has benefited from clinical knowledge when developing disease control interventions. However, the prevailing epistemological discourse offered clinicians only a minor role in public health programmes. Indeed, over the past half a century or so clinical disciplines allied to traditional public health programmes were usually mobilised according to a standard disease control pattern already outlined in 1965: [32].
• In theory, epidemiologists chose the priority diseases to be controlled. In practice, most of the current 132 international disease-specific programmes said to be ‘Global Health Initiatives’ are the result of commercial imperatives; epidemiological studies rarely entered the picture [33] Notice that access to care for the poor (roughly 70% of African and Indian populations) was largely limited to priority disease-control interventions, with fieldwork usually the responsibility of auxiliary health workers (and, to a lesser extent, first-line nurse practitioners). This increased the separation between public health activities and clinical medicine.
• Health economists set the programmes’ structures. Historically, they preferred vertical to horizontal programmes for considerations of efficiency. In practice, these programmes were operationally integrated in health care services but remained administratively autonomous, leading to dysfunctional management and bureaucratic inflation in low- and middle-income countries (LMICs) [8], so further weakening health systems in developing countries [34].
• Physicians and biologists decided the operational interventions to be led by public health programmes.
• Operational and implementation research (increasingly involving anthropologists) was established, for example to determine how to deliver these interventions and to improve population compliance [35].
• Finally, programme evaluations were left to economists and epidemiologists.
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The political imperative of this discourse was central to the development of the political economy of care in LMICs because it legitimised limiting public service’ activities to mere disease control on the grounds of cost-efficiency. In so doing, this epistemological discourse often misused allocative efficiency, which was confused with technical efficiency [36].
As a science of disease control, public health generally gave health care management short shrift. It frequently overlooked the often most important single health status determinant, i.e. healthcare. Thus public health specialists frequently neglected;
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The importance of the accessibility to care and its impact on population health (e.g., to improve early detection, care continuity, and yes, to recruit patients for public health interventions).
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The professional expertise required for the application of clinical and disease control guidelines.
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The multi-causality of disease with which clinical practitioners must grapple.
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The need to set conditional priorities within and between public health programmes.
Because these neglected themes are crucial to clinical and public health medicine, we question the very fact of their separation as well as the distinction between scientific and professional knowledge.
Integrated clinical/public health knowledge
We propose a typology based on a knowledge merger designed to inform medical education, training and research, which is consistent with the universal right to healthcare. Basing a typology of medical knowledge on concepts of cognitive psychology permits professionals to specify how knowledge is to be transmitted, taught, and assessed. This issue of medical knowledge transmission is crucial, as the written word does not lend itself well to improving the status of the patient, and the knowledge and behaviour of practitioners [37]. We have chosen one that is inspired by that of Malglaive and Piaget to define four categories of interdependent knowledge, namely, the skills; the procedural, the practical and the theoretical knowledge [38]. We shall see at the end of this section that these 4 categories are found in the structure of action research (AR), a research methodology particularly suited to the development of professional knowledge.
Skills
Behavioural skills include communication, emotional intelligence, reflection, conflict resolution, self-organisation, ability to balance work and life, time management, stress management, resilience, and patience. Together with manual skills, they are of primary importance in medicine. Manual skills are, of course, necessary in clinical medicine, but also in the interface with machines, for example in radiotherapy or endoscopic surgery. Skills are especially important in clinical medicine because they concern the clinician’s interaction with an individual and his/her family, However it may be argued that they are important also in public health, as disease control programmes should be negotiated with communities and authorities.
Skill transmission requires demonstrations, observations and technical supervision [39]. Teaching programmes should systematize skill acquisition. The importance of distinguishing skills from other health care knowledge appears to be understood in very few medical schools save some that have developed ‘problem-based learning’ programs: these are more the exception than the rule (Maastricht; Barts, Queen Mary; East Anglia; and Glasgow).
Procedural knowledge
Procedural knowledge is often defined as knowledge exercised in the performance of a task. We use it in the more restrictive sense of the knowledge required to apply clinical / public health guidelines (or standard operating procedures - SOP). The application of SOP guidelines is especially complex in medicine, because the principles of Evidence Based Medicine (EBM) require that the values underlying a SOP be compared with those of the patient so as to define the therapeutic process to be undertaken – an especially important challenge in multi-pathology, because achieving objectives in treating one disease may be detrimental to therapeutic effectiveness in another.
For medicine to serve the universal right to health care, clinical medicine and public health procedures must be integrated as frequently as possible. For example, general practice, paediatrics and gynaecology include a significant component of preventive medicine whilst preventive medicine in well-baby clinics, prenatal, and geriatric consultations can be partly standardised in order to rule out or treat relevant pathologies (of the new born and the infant, the pregnant woman and the elderly, respectively).
Clinical and public health guidelines should exhibit two critical characteristics that they frequently lack:
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Certain criteria for care quality can be defined at opposite ends of a notional scale, such as patient safety (with, for example, complaint medicalisation) and autonomy (vis-à-vis the disease and its medical solution), or the effectiveness and efficiency of treatment. If the doctor maximizes the first, (s)he reduces the second, and vice versa. To enable the physician’s to assess these guidelines in individual circumstances, guideline designers should make explicit the balance between the contradictory qualities of care criteria that govern their conception.
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Guidelines should offer alternative options to physicians to resolve clinical challenges (for example using different referral values) and so permit them to negotiate clinical treatment plans with their patients. Indeed, patients can only sensibly choose their treatment if alternative options and an explanation of their pros and cons are clearly offered. As for lifestyle clinical advice[s], it remains irrelevant if the patient does not have a choice. In practice, clinical guidelines rarely propose options, either because their commercially focused design only considers efficiency, or because their designers did not think of it.
The transmission and improvement of skills and procedural knowledge require educational supervision, intervision (mutual supervision), flow process auditing (to identify the hurdles a patient meets during his journey through the health system), action-research, and other reflective techniques. Medical faculties and health services should systematize the organisation of rotations and internships during medical training because this effects a lifelong improvement of problem-solving capacity of health professionals. In practice, faculties and health services rarely do so.
Practical knowledge
Malglaive [38] adds a ‘practical knowledge’ category that we apply to neo-Hippocratic medical practice and its management. Practical knowledge is needed to formulate advice[s] and norms for action in defined environments. It thus informs the design of new procedures and their use in new contexts.
To serve the universal right to healthcare, practical knowledge addresses a wide array of interconnected clinical and public health topics, with quality criteria addressing both domains. For example:
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The professionalization of physicians and that of other health proficients (e.g. in family medicine practiced by nurses in sub-Saharan Africa). Quality criteria may include ethical behaviour, problem-solving capacity, material conditions of the medical practice, and self-reflection capacity;
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The improvement of quality of care (for example through adding family therapy and social assistance to general practice);
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The optimisation of the clinical management of syndromes (say, gonorrhoea); of diagnosis and treatment of a given disease (say, the first and second line treatment of tuberculosis); of disease control (e.g.., diabetes or malaria within a defined area);
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Medical, disease prevention amongst high-risk groups (undocumented migrants in Belgium for instance);
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Improvement in access to health care (for example, access to general medicine) or to drugs for both the general population and for patients with special needs (e,g. patients referred to hospital);
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The optimisation of resource utilisation and procurement (drugs, medical equipment, finances, staff);
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The improvement of the health environment for patients and high-risk groups;
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The organisation of health services and systems (to improve, for example, care coordination between GPs and specialists).
The epistemic unit of practical knowledge can be defined as “strategy”, a representation of ways and means to achieve a goal. “Strategies” can serve as an action plan, action hypothesis, advice, standard, or the basis for an assessment. Strategies link endpoint objectives to a complex sequence of analysis, decision, action, and evaluation. To deal with complex realities they simultaneously address a number of resources, various processes, and many outputs – all topics on which the scientific public health literature is limited. Strategies can be described and evaluated and hypotheses about the conditions of their success or failure can be formulated to define their domains of validity. Multidisciplinary models and concepts are the ones that best describe such conditions. For example, the effectiveness of a vaccination program depends on the socio-cultural characteristics of the population (who decides? The father or the mother?); its geographical distribution; the characteristics of health services; the economic resources of families and those of the program; the level of competence of health professionals; etc.
The joint clinical and public health nature of practical medical knowledge appears in the process of integrating disease control in health care services, and in achieving this whilst strengthening, rather than undermining these services. Disease control programs can reduce access to care in the setting in which they are integrated, imposing on them multiple lines of authority; setting ill-defined priorities and increasing opportunity costs. Inadequate budgets, financial overruns and unrealistic costing; tension between health care professionals over income disparity and problems with sustainability are all too frequent characteristics of such programmes.
The essence of practical medical knowledge is professional and not merely scientific, because:
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The practical knowledge acquired by clinicians and public health physicians should reduce any uncertainty in decision-making, improve programme implementation, promote reflectivity (the quality to reflect i.e. redirect back to the source), and enhance the relevance of evaluation.
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To promote the correct use of EBM, [40] end-user physicians should adapt clinical guidelines to local (epidemiological, cultural, economic, medical) conditions [41]. This is the method by which GPs and the EBM Practice Net adapted the Finnish Duodecim guidelines to Belgian conditions.
Unfortunately, in guiding physicians, Health Maintenance Organisations (HMOs) and government administrations have often over-relied on a biased, unnecessarily strict interpretation of ‘scientific’/biomedical EBM. They continue to apply it despite overlooking medical regulation, [42] neglecting multi-morbidity challenges posed by ageing populations [43,44,45] (guidelines often map poorly with complex multi-morbidity), [22] and disregarding aspects of care that escape standardisation.
As a professional endeavour, the transmission of practical knowledge benefits from exchanges based on the experience of learners, and exchanges between them and their teachers. Scientific representations are often an inappropriate method to transmit this.
Theoretical knowledge
Theoretical knowledge relates to the laws of existence and the constitution and functioning of reality – i.e., why something is true. Theoretical knowledge teaches reasoning, techniques and theory of knowledge. Below, we examine some of the characteristics of the theories that support medical professionalism.
First, they often rely on interconnected clinical and public health concepts. One can only understand domestic violence, against women, for example, with concepts of sociology (this violence is not explained in the same way in endogamous and exogamous societies because the free sexuality of women threatens the family architecture of endogamous societies much more than that of the others).
Likewise, consider a basic task of a clinician: diagnosis. Clinical epidemiology and epidemiology ought to be taught together, because the positive predictive value of a sign, a symptom or a test result is a function of the disease prevalence expressed as:
$$ \mathrm{PPV}=\left(\mathrm{SS}\ \mathrm{X}\ \mathrm{d}\right)/\Big(\left(\mathrm{SS}\ \mathrm{d}+\left(1-\mathrm{SP}\right)\left(1-\mathrm{d}\right)\right). $$
Where PPV is the positive predictive value of a sign or a test; SS is its sensitivity; SP is its specificity; and d is the disease prevalence [46].
This formula shows that the predictive value of a sign, symptom or test depends on the local prevalence of the disease that it predicts. Therefore, the value of a symptom is not the same in the patient base of GPs compared to specialists. The physicians’ clinical experience is therefore radically different. Nevertheless, in most universities, it is mainly specialists who teach semiology to the future GPs.
Second, professional research methodologies are interdisciplinary, not merely multidisciplinary. Interdisciplinarity is the interaction between disciplines. It leads to the mutual integration of concepts and methodologies while multidisciplinarity is the simultaneous use of sciences belonging to different fields. Interdisciplinarity opens the door to ad-hoc, original study methods and is often a sine-qua-non for the relevance of theoretical work [47] that (in this case) supports the practice of medicine. Unfortunately, universities today undermine interdisciplinarity with a competition linked to research finance; the publication race; reduced advancement prospects suffered by academics who maintain a professional practice; and scientific specialisation as the basis for career strategies.
Third, medical curricula often neglect two disciplines pivotal to understand and support the personal, professional development of physicians: psychology and philosophy. A knowledge of professional psychology is indispensable in understanding physicians’ intangible motivations and professionals’ wellbeing in general [48]. Values that govern (and should govern) medical and public health practice are derived from moral philosophy.
Finally, policy studies and health systems research should pay attention to the political sciences, [49] the political economics of health care, and history, because the construction of national health systems spans generations and history reveals the political, economic and social determinants of health structures, medical cultures and praxis. In practice, health policy studies rarely set outcomes in context as reputable journalist would.
This typology of medical knowledge closely overlaps the stages of action research:
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The design of a strategy (for example, to control AIDS) requires practical knowledge. A sound strategy is a prerequisite to develop procedures, such as the conduct of a follow-up consultation.
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Procedures are always implemented relying on the doctor’s procedural knowledge and know-how.
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The strategy design depends on the problem it intends to solve, on prior (practical and theoretical) knowledge and on a model (that represents the characteristics of the environment, the problem, the strategy and its expected effect).
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Finally, the strategy evaluation assumes the assessment of its design and of the procedures implementation.
Even though medical interventions benefit from science, they are, in essence, professional: science cannot standardise eco-biopsychosocial decisions; doctor-patient negotiations; emotional intelligence; manual and behavioural skills; and resolution of ethical conflicts.
