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There is now a need to consider the Neo-Polanyian proposal as a conceptual aid for a viable alternative to the scientific model of clinical medicine wedded to the mechanistic model.

The Neo-Polanyian proposal has implications for clinical medical practice as skilful knowing of disease in patients-as-persons experiencing disease. According to Polanyi, his Personal Knowledge model of scientific insight is the model for all knowing, theoretical and practical. I take my point of departure from here. My focus will be on epistemology and ontology.

3.1. The Present Relation Between Philosophy and Medicine and Why a Personal Knowledge Philosophy is Needed

As it came to light in a letter to the editor of Theoretical Medicine, there is a slowly spreading belief "that studies in medical ethics without a solid grounding in the epistemology of medicine will be seriously flawed."[18] (pp. 87-90) The authors note that scientific knowledge is perceived as morally unproblematic, whereas the application of this knowledge is perceived as giving rise to moral problems.

Focusing on one of these "unproblematic" areas, Rosen suggests that perhaps what should be looked at is a too narrow view of objectivity, especially identifying "objectivity" with what a "(body as a) machine" can do.[19] (pp. 90-100) He shows that a reductionistic view such as this, especially in biology, denies final causation and the possibility of explaining complex living systems. In the reductionist view, according to Rosen, "objective" explanations mean explaining wholes in terms of parts, not parts in terms of wholes. Final causation, in his view, means closed causal loops strong in entailment, an anticipatory system. Biology, he states, requires explanations which allow an anticipatory system, the notion of function dependent on an environment. Such anticipatory systems require "closed causal loop" explanations rich in entailinent. Explanations using unidirectional (open and weak, linear) causal entailment are applicable in simple systems such as machines. Reductionist explanations deem only open causal chains objective, and consider closed loops of anticipatory systems forbidden in science. Exclusion of anticipatory systems would exclude biological systems from science as "non-objective"; this would mean that "the `mind-brain problem' falls irretrievably outside of science" [19] (p. 92) In his proposal, "mechanism" (explanations of the body as a machine) would become a limiting case of complexity.

As this discussion shows, there is an awareness again for a need for ontological foundations and epistemological inquiries.

Historically, the perceived relevance of philosophy to medical practice in general has decreased with the ascendance of "scientific medicine". Great progress has been made in science, including medical science in the nineteenth century; however, little of the scientific progress of that time has been translated into clinical practice. In 1910 the Flexner Report.2o (p. 297) was issued to establish criteria for good medical practice. This report had enormous impact - it was the beginning of scientific medicine as we understand it today.

The scientific model of a mechanistic conception of the body was carned into the core of medical practice, of clinical diagnosis of disease. Physician and medical historian Lester King explains:

Much of medical education centers around the problem: how do you learn to make a diagnosis? One recent text gave this advice: the student should "begin, as in all scientific research, by marshaling all the facts, then proceeding with an unprejudiced analysis of the facts, and end with a logical conclusion".[20] (p. 90)
The so-called Baconian "scientific method" is presented in this text. However, as Polanyi has shown, this is not how scientific research is done. It is also not how experienced physicians make a diagnosis. An extensive study by Elstein et al. on clinical problem-solving reports: "A major finding of the research . . . is that nearly all experienced physicians began to generate diagnostic hypotheses, or problem formulations, within the earliest minutes of a clinical encounter."[21] (p. 168)

However, problem-solving does not proceed from a firm hypothesis to its iron-clad proof. The authors of this study continue:

Diagnostic problems are solved through a process of hypothesis generation and verification. Hypotheses are consistently generated early in a workup when only a very limited data base has been obtained. While any early formulation may be revised or discarded if subsequent data fail to confirm it, there is a high probability that at least some of the formulations of experienced physicians will be correct. Hypotheses serve as organizing rubrics in working memory.[21] (p. 113)
This picture of problem-solving suggests that the initial hypothesis is a "best guess" in Polanyi's sense, which fturther work may confirm. Evidence of expertise, Elstein says, is in the thoroughness of cue acquisition and accuracy of cue interpretation. Recognizing the diagnostic significance of a cue and "putting cues together" are crucial. Polanyi would suggest that neither of these procedures can be said to be entirely rule-following, rather they are mostly skills of perception, acuity of seeing connections and reliance on latent knowledge.

Elstein's study reports that in expert clinicians initial problemformulations seem to be made non-consciously: "It may be that for the experienced physician the utilization of [pathophysiological] knowledge is so well established . . . that he is no longer consciously aware of its use in generating problem formulations" [21] (pp. 193-194) In Polanyi's terms, the clinician's knowledge is in subsidiary awareness. So are many of the clues he formulates into his initial hypothesis. The initial hypothesis formation may be thought of as akin to aesthetic recognition in the sense of an instantaneous apprehension of many kinds of relationships at the same time.

The Elstein's study chose not to include an investigation of doctorpatient relationshipsõ as part of the problem-solving process, either in the workup (history taking) or in the management phase (through final diagnosis and exit) of the clinical situation. This relationship must be included in a Polanyian and Neo-Polanyian conception of the process of problem-solving in the clinical setting.

3.2. Neo-Polanyian Approach in Clinical Practice; Roles of the Tacit and the Explicit

I would suggest that, first, the above valuable description of problemsolving can be interpreted in terms of a Polanyian model of tacit knowing, and second, that by eliminating the doctor-patient relationship in general and concentrating on the physician's scientific knowledge as the "content" on which his reasoning processes functioned, left out a much larger tacit content operational but not acknowledged in the clinical situation.

My proposal is not simply a phenomenological or existential approach to the clinical situation - these anti-mechanistic approaches have already been tried, but have made little inroads in mainstream somatic medicine in this country.# The reason may be not only that, as Richard Baron M.D. suggests "ultimately the phenomenological perspective must be translated into something people do . . . [that] it may be comprehended and incorporated into clinical practice;"[22] (p. 38) rather, the reason may be that there is an "either-or" approach, a drive for complete replacement, "as we exhort ourselves and our students to trade in our positivist bodies for phenomenological embodiment"[22] (p. 37)

This exhortation disregards what, by Baron's admission, doctors see as their major responsibility: to keep up with the advancement of scientific medicine, to know what is "do-able". Baron offers no structure to connect the two seemingly contradictory demands - for humanistic "soft" approach to the phenomenological person of the patient, and for scientific "hard" approach to the biomedically knowable bodily mechanism of the patient.

My Neo-Polanyian proposal resolves the "contradictoriness" of these demands. It is an approach which by-passes the either-or "trading in of paradigms," yet is grounded in the medical problem-solving process study I introduced above. It also takes into consideration phenomenologicalexistential insights into a person I have discussed earlier. I suggest we start with Polanyi's end-point: that there are two kinds of awareness, subsidiary and focal, and that the notion to understand the person as a mind-body relation, we need two distinct conceptions of tacit knowing - "from-to" conceptions and "from-at" conceptions.

For the sake of clarity, the description of the distinction of "from-to" and "from-at" knowing is somewhat simplified in our demonstration. As I noted above, "from-at" indirect knowing is the interpreting of the patient's mental experience based on direct "from-to" knowledge of his physiological processes, interpretation conceived of as a function of inference combined with imagination. Schematically "from-at" knowing is:

{physician ~ patient's physiology (body)
~ patient's pain-experience (mind) }

That is, the physician's direct "from-to" scientific knowledge is extended by interpretation, becoming the indirect "from-at" knowledg of the patient's pain-experience, the "clinical case".

Knowing a person as a person (existential being) is also direct "from-to" knowing. Humane clinical medicine is to incorporate this element. Schematically the clinical situation (CS) now becomes the new integration of the scientific and the humane elements (E):

E{physician - [from-to]I -~ person, physician - [from-at]1 -~ "the case"} ~ CS{physician - [from-to]2 ~ patient as body-mind}.

Here integration is defined as the intelligent reorganization of elements into a new more complex whole. I want to apply these notions to improve on Baron's "exhortation" method.

To fill out the schema, I will start from the position that the patient is an ontological entity. In Polanyi's scheme, he is a hierarchical (stratified) entity of body-mind relation, and, as such, the meaning of his being is his mind (the mind is the meaning of the body). The physician, another being, can know the patient as a person by the kind of understanding Polanyi called "indwelling".[16] As he said, ". . . our perception of living beings consists largely in mentally duplicating the active co-ordinations performed by their functions. To this extent our knowledge of life is a sharing of life - a re-living, a very intimate kind of indwelling". [16] (pp. 15-151) Our way of knowing is tied to our way of being. This, I would suggest is the "from-to" conception of knowing the patient as a person that the physician needs to employ as the foundation of the clinical relationship.

To give structure to the clinical relationship in terms of the NeoPolanyian approach, I suggest the physician begins with such "from-to" knowing of the patient as a person. In practical terms, this means a perceptive active empathic resonance before and during history taking. The next step is assessing "the case". Since the clinical situation is generally speaking not a "well-formed problem" in the strict scientific sense, but a presentation of a "complex" by a patient, the physician's task is in two stages - problem-formulating: "What is wrong with this patient? What are the symptoms? What are the possible diagnoses?" and problem-solving: "How can I solve his problem? What is the most likely diagnosis? What treatment options are there?" Here the physician focuses on the biological mechanisms of the body and focuses only indirectly on the patient's painexperience. This is the "from-at" conception of knowing the patient as the "clinical case."

If the physician's interaction with the patient is limited to "from-at" knowing of the patient, his "at-knowledge" of the patient's problem is from the "outside" and is not integrated to the patient's pain-experience.## Furthermore, if the physician de-emphasizes the imagination component of interpretation in his "from-at" knowing and equates the patient's pain experience with his knowledge of the physical aspects of the disease (his from-to knowing of the body), the patient becomes objectivized, a situation which can lead to a detached attitude of the physician, an attitude called "mechanistic" by Baron.

Since the problem-solving process often proceeds following various stages from workup through management to exit, the physician needs to deliberately shift focus several times between "from-to" knowing and "from-at" knowing.

It must be emphasized that the "from-to" concept of knowing is more fundamental, i.e., the "from-at" conception of knowing for the purpose of problem-solving is supervened by "from-to" knowing in the doctor-patient relationship. According to the conception of Integrative Philosophy, some aspects of the body lend themselves to biomechanical explanations, but such explanations always have to keep in mind that they are "as if" explanations: the body is not simply a mechanism.[23] The body has a mechanical aspect in that "parts" are functionally coordinated in a "whole". We must avoid equating the model with the patient, lest the patient becomes objectivized.

It is necessary to clarify the roles of the tacit and the explicit in this process and to relate them to the "from-to" and the "from-at" conceptions.

The two conceptions of knowing, "from-to" and "from-at" knowing of stratified entities, will not operate as either-or trading in of paradigms during the changes in focus. That is, one conception is not rejected in favor of the other. In the Neo-Polanyian proposal, when the physician is approaching the patient initially in the "from-to" mode of knowing, he is approaching the patient as a person, his clinical "from-at" mode of knowing will be latent, ready to be drawn upon as needed. At this point, the "from-at" mode of knowing is in subsidiary awareness along with other clues (not yet explicit but) which will contribute to the initial hypothesis in problem-solving. Later the initial hypothesis or hunch would include the perception of the patient as a person. In the stage where scientific problemsolving is predominant, the "from-at" mode of knowing ("the case") is in operation and the initial "from-to" mode (approaching the person as existential being) is latent, it is in subsidiary awareness. Since the subsidiary awareness contributes to focal awareness in the total meaning of the situation, the phenomenological-existential knowledge of the patient is still operational.

During most of the process of patient management and towards the stage of exit, "from-to" knowledge will again predominate, but at a higher level of integration than at the initial stage. This is necessary, as I said, because in the conception of Integrative Philosophy, the mind is the meaning of the body, i.e., to bring about wellness, the whole patient as mind-body needs to be attended to.

The periodic shifting of focus between "from-to" and "from-at" awareness is needed to attend to the task of the clinical situation - attending to the body, attending to the mind and attending to the body-mind - specifically to avoid the paralysis caused by attempting to focus on both the biological body and the existential person (mind) at the same moment during treatment. This paralysis is the reason Baron's exhortation will not work. One cannot have two foci of attention, body and person, simultaneously. Also, one cannot have two levels in focal attention at the same time, in this case, one directed to the level of the patient's body, the other directed to his existence as body-mind simultaneously. The key to the solution of Baron's problem is that one can have several "elements" and modes in subsidiary awareness however, while attending to something in focal awareness. When the physician strives for the higher level integration to focus on "the patient as body-mind," his emphasis is on the embodied mind. The initial focus on "the case" and the focus on the "person" will be in subsidiary awareness.

The shift in focus recommended here is not impossible. Learning to shift focus is a skill already developed in medical training in diagnostics, as illustrated by Polanyi's example:

[A] distinguished psychiatrist demonstrated to his students a pafient who was having a mild fit of some kind. Later the class discussed the question whether this had been an epileptic or a hysteroepileptic seizure. The matter was finally decided by the psychiatrist: "Gentlemen," he said, "you have seen a true epileptic seizure. I cannot tell you how to recognize it; you will learn this by more extensive experience".

The psychiatrist knew how to recognize this disease, but he was not at all certain how he did this. In other words, he recognized the disease by attending to its total appearance and did so by relying on a multitude of clues which he could not clearly specify. Thus his knowledge of the disease differed altogether from his knowledge of these clues. He recognized the disease by attending to it, while he was not attending to its symptoms in ! themselves, but only as clues. We may say that he was knowing the clues only by relying on them for attending to the pathological physiognomy to which they contributed. So if he could not tell what these clues were, while he could tell what the disease was, this was due to the fact that, while we can always identify a thing we are attending to, and indeed our very attending identifies it, we cannot always identify the particulars on which we rely in our attending to the thing. . . .

There are two kinds of knowing which invariably enterjointly into any act of laiowing a comprehensive en6ty. There is (1) the knowing of a thing by attending to it, in the way we attend to an entity as a whole by focal awareness], and (2) the knowing of a thing by relying on our awareness of it, in the way we rely on our awareness of the particulars forming the entity for attending to it as a whole by subsidiary awareness].

Gestalt psychology has proved quite generally that we cannot focus our attention on the parculars of a whole without impairing our grasp of the whole; and that conversely, we can focus on a whole only be reducing our awareness of the particulars to the contribution they make to the whole. We may call the latter subsidiary awareness of the particulars in terms of our lmowledge of the whole that is subserved by them.

As a rule, the two alternative kinds of knowing do not completely extinguish each other. We may successfully analyze the symptoms of a disease and concentrate attention on its several particulars, and then we may return to our conception of its general appearance by becoming once more subsidiarily aware of these particulars as contributing to the total picture of the disease. Indeed, such an oscillation of detailing and integrating is the royal road to deepening our understanding of any comprehensive entity.[24] (pp. 118-119)

In Polanyi's terms, diagnostics is a process of oscillation between analysis and integration in successive stages until the problem is solved. The process in this context is of solving the problem for a biological entity, diagnostics. The process in the clinical context is analogous, but the integration is one level of complexity higher: diagnostics becomes analogous to one of the "particulars" (the existential person is the other "particular") and patient as body-mind is analogous to "whole". Therefore, the "oscillation" on the lower level is between analysis of symptoms and the concept of the disease-complex, and on the higher level the oscillation is between diagnostics of "the case" ("from-at knowing") and healing ("from-to knowing"). The mechanism of oscillation and the resultant deepening of knowledge is the aim of integration. The driving force of scientific "from-to" knowing is heuristic striving (intellectual passion), the driving force of the existential "from-to" knowing is active empathy (humane passion); the driving force of interpretation in "from-at" knowing is the imagination component of heuristic striving. Imagination also functions, as I said earlier, as the hook between the existential and the scientific "from-to" knowing. On the higher level of integration, the driving forces are conjoint, aiming at healing the patient as body-mind. The indirect mode of viewing the patient as "the case" is supervened but not eliminated, it is absorbed into the new integration.

This process of integration is learned only in practice, in apprenticeship, and communicated by example not by explicit instruction. Polanyi considered apprenticeship an immersion in scientific tradition monitored by the authority of one's professional peers and seniors. He likened the skill of medical diagnostician to connoisseurship, a fusion of the "art of knowing" and the "art of doing". The same can be said of the skill of healing. However, without training in understanding of the ground (ontology), without understanding the nature and justification for the kind of knowing (epistemology) presented here, the skill acquired would be mere routine, and as such could not be employed intelligently and creatively to fit new and unforeseen situations.


The process of "from-to" knowing presented above is well described in the analysis of "intellectual passion" (heuristic striving). In the proposed approach, a Neo-Polanyian medical epistemology, there is an additional integration of elements which are drawn from the initial "from-to" and "from-at" processes: this integration is by active empathy (humane passion) conjoined with heuristic striving (intellectual passion) paralleling the function of "intellectual passion" in scientific discovery. The culmination of the intellectual effort of the physician or of the scientist is an integration of elements - from memory, imagination, heuristic striving in the meaning of the action: the act of curing or a discovery. But the physician's effort is greater because the meaning of his action goes beyond curing to healing, which requires the additional driving force of active empathy.

Technically virtuoso performance in general may be understood as described in the Gestalt-Perception Model and the Action-Guiding Model presented at the beginning of this study. A purely phenomenologicalexistential "lived experience" notion like Merleau-Ponty's concept is inadequate for the scientific way of knowing because it does not deal with the logical relations of scientific knowing.[17] (p. 237) For this reason Baron's project is bound to fail. The third, the Semiotic Model, carries within it the richness of the previous two models. It would be the model for clinical practice, with the additional proposal I have just made: the integration of "from-at" knowing and "from-to" knowing into a higher level of "from-to" knowing by the joint driving forces of intellectual-humane passion. This approach brings together the ontological ground and the understanding brought by epistemology.

My proposal in this paper s that the clinical situation in somatic medicine could benefit by considering an alteration in the mode of knowing presently used, in the direction I outlined. What is needed is an acknowledgment that a broadening of the mode of attending to the patient as an ontological mind body entity will enhance the effectiveness of the practice of medicine without handicapping the scence of medicine. The above proposal for a Neo-Polanyian medical epistemology is an exploration of a framework for this broader approach.


Thanks are due to Israel Scheffler, Marjorie Grene and Alfred Tauber for commenting on an early version of this essay, to the reviewers for valuable suggestions on the 1995 version, and to Evert van Leeuwen for editorial help.

I will not discuss other alternatives such as holistic medicine, the European version of medical anthropology, or the many versions of oriental medicine. My intention is to show how Polanyi's epistemology and ontology apply to clinical practice.

For a pedagogic approach of "problem-based learning" in which the doctor-patient relationship is more central, see Daniel C. Tosteson et al. New Pathways to Medical Education. Harvard University Press, 1994. New Pathways' theoretical foundation is constructivist psychology.

# Existential and phenomenological interpretations have been used in psychiatry. For example, see Medard Boss, Existential Foundations of Medicine and Psychology, trans. from German by S. Conway and A. Cleves. New York: Jason Aronson Pub. 1979. Also, Drew Leder, ed., The Body in Medical Thought and Practice. Dordrecht: Kluwer Academic Press. 1992. Philosophy and Medicine series Vol. 43.

For an approach resembling Polanyi's use of tacit knowing, see Theodore Reik. Listening with the Third Ear. 1948, New York: Pyramid Books, 1964, especially Ch. 14, "Conscious and Unconscious Observation", and Ch. 18, "Insight". I am indebted to I. Scheffler for reminding me of this resemblance.

## Adapted from Polanyi. Life's irreducible structure, Knowing and Being, Essays by Michael Polanyi, ed. Marjorie Grene. Chicago: The University of Chicago Press, 1969: 237.

18. De Cuzzani P and Lie RK. The importance of epistemology for clinical practice. Theoret Med 1991; 12: 87-90.
19. Rosen R. Drawing the boundary between subject and object: Comments on the mindbrain problem. Theoret Med June 1993; 14(2): 90-100.
20. King LS. Medical Thinking: A Historical Preface. Princeton: Princeton University Press, 1982.
21. Elstein AS, Shulinan LS, Sprafka SA. Medical Problem Solving: An Analysis af Clinical Reasoning. Cambridge: Harvard University Press, 1978.
22. Baron, Richard J. Why aren't more doctors phenomenologists? In: Leder D, ed. The Body in Medical Thought and Practice. Philosophy of Medicine Series Vol. 43. Dordrecht: Kluwer Academic Press, 1992.
23. Polanyi M. Letter to Charles C. Gillispie, 30th June 1966. Polanyi Papers (6:8). J. Regenstein Library (see cit. above).
24. Polanyi M. Faith and reason (1961). In: Schwartz F, ed. Scientific Thought and Social Reality: Essays by Michael Polanyi. New York: International Universities Press, Inc., 1974.

Polanyiana Volume 8, Number 12, 1999

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