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BOOK REVIEWS

The Reflective Practitioner: How Professionals Think in Action Donald A. Schiin, Basic Books, New York, 1983

This volume, subtitled “How Professionals Think in Action,” is an inquiry into the epistemology of profes- sional practice. The author begins with the assumption that competent practitioners usually know more than they can say. Further, “. . . practitioners themselves often reveal a capacity for reflection on their intuitive knowing in the midst of action and use this capacity to cope with the unique, uncertain, and conflicted situa- tions of practice. ” To understand this knowledge gained from action, the author examines a sample of vignettes of senior practitioners trying to help junior ones learn to do something.

The book is divided into three parts. Part 1, “Profes- sional Knowledge and Reflection-in-Action,” intro- duces the reader to the philosophic orientations and the concepts used in the study of the knowledge of practice. Chapter 1 explores the crises of confidence in profes- sional knowledge. It is here that “artful practice” of competent practitioners is identified as an important area for inquiry. The dominant philosophic view of pro- fessional knowledge, technical rationality, and its limitations in accounting for what competent practition- ers do in “divergent” situations, are discussed in Chap- ter 2. The argument then is made for the study of reflection-in-action to establish it as a legitimate form of professional knowledge. As a part of the argument, the features of reflection-in-action are defined.

Part 2, “Professional Contexts for Reflection-in- Action, ” contains examples of professional practice, which are explored in light of a set of questions con- cerning the reflection-in-action. The examples are drawn from architecture, psychotherapy, engineering design, town planning, and management. Through analysis of these examples, the author identifies the structure, patterns, and limits of reflection-in-action. Chapter 5 is especially useful in understanding sub- sequent chapter analyses. Chapter 9 expressly focuses on the patterns and limits of reflection-in-action.

Part 3, “Implications for the Professions and Their Place in Society, ” summarizes in one chapter tire pre- ceding chapters. Implications of reflection-in-action as a legitimate form of professional knowledge and practice are drawn for the professional-client relationship, re-

search and practice, the institutional contexts of profes- sional work, and the place of the professions in the larger society.

This volume should be of most value to academicians in professional schools. The discussions of the tradi- tional views of research and practice contrasted with reflection-in-action are of particular interest. The prep- aration of reflective practitioners, to be explored in a future volume, is briefly discussed. Practitioners, in turn, may be stimulated to become reflective in their practice. The strengths of the book for them may be offset by its basic orientation, that of inquiry rather than prescription. The examples used for analysis, except for the one drawn from psychotherapy, are from contexts outside the health-care arena. To this reviewer, implica- tions of the author’s work for further study and elucida- tion are the ones that are most compelling.

Cynthia J. Stewart, M.P.H., Ph.D. School of Public Health University of Michigan

The Social Organization of Doctor-Patient Communication Sue Fisher and Alexander Dundas Todd, eds., Center for Applied Linguistics, Washington, D.C., 1983

“One of the amazingly simple insights about medical treatment is that it is conducted in language. ” With this concise and profound introduction, Fisher and Todd go on to present the reader with ten articles that demon- strate some of the complexities and problems of physician-patient communication.

It is not unusual nowadays to hear complaints about medical care and interactions with physicians. Underly- ing the outrage over costs is a nagging concern that doctors speak a different language, do not listen, and fail to communicate with their patients. The media model of the physician who is kindly, personable, and always available for hours of counseling and advice does not exist in most of our experiences with the medi- cal industry.

The ten chapters in The Social Organization of Doctor-Patient Communication examine how doctors and patients communicate, how they exchange or fail to exchange pertinent information, and how they interpret and act on that information. These articles address real

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problems of misunderstanding, informed consent, question-asking (who asks and who gets answers), treatment negotiations, interference, beliefs, clinical reasoning, and biases of doctors that influence their per- ceptions of patient competence.

Since examining doctor-patient communication is still a relatively recent development, this work, not surpris- ingly, tends to emphasize the negative rather than posi- tive aspects. Marianne Paget presents an intriguing and disturbing analysis of the effect of asymmetries and dis- harmonies in doctor-patient conversation. This is sup- ported later by Fisher’s analysis of negotiating treatment decisions. She states, “Patients enter medical interac- tions from a position of relative weakness.” Further- more, “An analysis of the strategic use of language suggests that practitioners have power that patients lack, a power manifested and reflected in how practitioners present information to patients.” This view is also sup- ported in much of the cited research and in other chap- ters. Todd, in her chapter, points out that the way lan- guage is used in a medical relationship highlights and maintains the doctor’s power. The physician talks and questions while the patient merely responds most of the time. Shut-y examines the negative effect of interview style versus normal conversation on doctor-patient rela- tions and the information shared.

Several authors cite the particular problems of com- munication between doctors and their female patients. The male doctor’s perception of his female patients’ competence to make decisions has a profound affect on treatment selection and suggestion of alternatives.

The Social Organization of Doctor-Patient Communi- cation is a well researched and well written book. It offers a variety of perspectives on language in its medi- cal context from detailed linguistic methods used to analyze conversation segments and concurrent physical interactions captured on videotape to general descrip- tions of physician-patient interactions. Each writer interviewed patients and observed doctor-patient interac- tions in the medical setting as part of their research. The research cited is current and well referenced.

Readers of this book who are involved in patient edu- cation and counseling will find information that, while not surprising, may be helpful. The various authors illustrate common problems and pitfalls of communica- tion between the patient and the medical community. The patient educator-counselor may be able to alleviate some of these problems through increased awareness and development of good interpersonal communication skills. Physicians could also benefit from the insights and observations of the book by examining their own communication skills and changing those that could lead to similar problems.

The Social Organization of Doctor-Patient Communi- cation touches on a critical aspect of the relationship between medicine and the public. It contains valuable

information that could be useful to any health-care professional. Most of the articles are readable and easily understood regardless of one’s background in linguis- tics. The book does not directly suggest strategies for changing or improving doctor-patient communication, but it does point out rather strongly the critical need for the inclusion of this type of training in the education of medical personnel.

Christine Parks* Borgess Medical Center Kalamazoo, Michigan

Delivery of Rural Mental Health Services Anthony M. Falcone and Ted L. Rosenthal, Synapse, Inc., Cleveland, and The Boxwood Press, Pacific Grove, California, 1982

This is the first volume in a new series, Monographs in Psychiatry and Psychology, which will provide a forum for brief reviews, monographs, and collections of papers that do not appeal to the mass markets. This series will emphasize authorship rather than editorship. Delivery of Rural Mental Health Services contains summaries of the different types of research that have been done on rural mental health service delivery. Anthony Falcone points out that the book is for individ- uals such as administrators who question the need for researching treatment and service delivery effectiveness.

The book consists of eight chapters, which can easily be read within a few hours. Each chapter is well refer- enced with literature on mental health delivery. The authors also suggest ways to improve’ the quality of research and research reports. By summarizing most of the research accounts, the authors may tease the readers into looking up the original sources to understand the studies quoted.

Different aspects of this book will appeal to different readers’ interests, as it deals with a range of rural de- livery systems, from those that are still in the initial stages to those that have been providing services for many years. The introductory chapter, “The Context of Rural Service Delivery, ’ ’ defines what a rural service delivery system is. While the authors present many studies on rural mental health problems, much more has to be done to adequately identify all the needs. A number of comparisons are drawn between rural and urban mental health issues, but the suggestion is also made that more studies must be done on rural problems and needs since they are different from urban problems.

In “Social Perceptions of Psychiatric Problems, Pa- tients , and Treatments, ” the authors review up-to-date

*Member of the Special Patient Education Book Review Committee composed of members of the Michigan Society for Health Care Man- power Education and Training and the Great Lakes Chapter, Society for Public Health Education.

PATIENT EDUCATION AND COUNSELING