The Reflective Practitioner

Part I

PROFESSIONAL KNOWLEDGE AND REFLECTION-IN-ACTION

1

The Crisis of Confidence in Professional Knowledge

The professions have become essential to the very functioning of our society. We conduct society’s principal business through professionals specially trained to carry out that business, whether it be making war and defending the nation, educating our children, diagnosing and curing disease, judging and punishing those who violate the law, settling disputes, managing industry and business, designing and constructing buildings, helping those who for one reason or another are unable to fend for themselves. Our principal formal institutions—schools, hospitals, government agencies, courts of law, armies—are arenas for the exercise of professional activity. We look to professionals for the definition and solution of our problems, and it is through them that we strive for social progress. In all of these functions we honor what Everett Hughes has called “the professions’ claim to extraordinary knowledge in matters of great social importance”;¹ and in return, we grant professionals extraordinary rights and privileges. Hence, professional careers are among the most coveted and remunerative, and there are few occupations that have failed to seek out professional status. As one author asked, are we seeing the professionalization of nearly everyone?²

But although we are wholly dependent on them, there are increasing signs of a crisis of confidence in the professions. Not only have we witnessed well-publicized scandals in which highly esteemed professionals have misused their autonomy—where doctors and lawyers, for example, have used their positions illegitimately for private gain—but we are also encountering visible failures of professional action. Professionally designed solutions to public problems have had unanticipated consequences, sometimes worse than the problems they were designed to solve. Newly invented technologies, professionally conceived and evaluated, have turned out to produce unintended side effects unacceptable to large segments of our society. A professionally conceived and managed war has been widely perceived as a national disaster. Professionals themselves have delivered widely disparate and conflicting recommendations concerning problems of national importance, including those to which professional activities have contributed.

As a result, there has been a disposition to blame the professions for their failures and a loss of faith in professional judgment. There have been strident public calls for external regulation of professional activity, efforts to create public organizations to protest and protect against professionally recommended policies, and appeals to the courts for recourse against professional incompetence. Even in the most hallowed professional schools of medicine and law, rebellious students have written popular exposés of the amoral, irrelevant, or coercive aspects of professional education.³

But the questioning of professionals’ rights and freedoms—their license to determine who shall be allowed to practice, their mandate for social control, their autonomy—has been rooted in a deeper questioning of the professionals’ claim to extraordinary knowledge in matters of human importance. This skepticism has taken several forms. In addition to the public loss of confidence noted above, there has been a virulent ideological attack on the professions, mostly from the Left. Some critics, like Ivan Illich, have engaged in a wholesale debunking of professional claims to special expertise.⁴ Others have tried to show that professionals misappropriate specialized knowledge in their own interests and the interest of a power elite intent on preserving its dominance over the rest of the society.⁵ Finally, and most significantly, professionals themselves have shown signs recently of a loss of confidence in their claims to extraordinary knowledge.

As short a time ago as 1963, Daedalus, the highly regarded journal of the American Academy of Arts and Sciences, published a volume on the professions that began, “Everywhere in American life, the professions are triumphant.” The editors of Daedalus found evidence of triumph in the new visibility of the professions, the growing demand for their services, and their expansion in nearly all fields of practice:

We already devote an impressive percentage of the gross national product to the training of professionals . . . and the day is coming when the “knowledge industry” will occupy the same key role in the American economy that the railroad industry did a hundred years ago . . . At the midpoint of the fifteen year period (1955–1970) in which we are attempting to double the number of college professors—an awesome task which is made even more difficult by the simultaneous and equally grandiose expansion plans of all the other traditional professions, the spectacular proliferation of new professions and the increasing professionalization of business life—America has become more cognizant of the professions, and more dependent on their services, than at any previous time in our history. Thorsten Veblen’s sixty-year-old dream of a professionally run society has never been closer to realization.⁶

The editors of Daedalus were by no means alone in their assessment of the situation. It was generally believed both that social needs for technical expertise were growing and that, as a cause and consequence of this growth, a professional knowledge industry had come into being. Richard Hofstadter wrote of the once self-sufficient “common man,”

he cannot even make his breakfast without using devices, more or less mysterious to him, which expertise has put at his disposal; and when he sits down to breakfast and looks at his morning newspaper he reads about a whole range of vital and intricate issues and acknowledges, if he is candid with himself, that he has not acquired competence to judge most of them.⁷

In his commencement address at Yale in 1962, John Kennedy had urged his young audience to “participate . . . in the solution of the problems that pour upon us, requiring the most sophisticated solutions to complex and obstinate issues.”⁸

There were many references to a “second scientific revolution” which was producing a “knowledgeable society,”⁹ an “active society,” a “post-industrial society,”¹⁰ organized around professional competence.

The prodigious and increasing resources poured into research, the large and increasing numbers of trained people working on various natural and social “problems,” and the expanding productivity resulting from this work is, at least in size, a new factor in social and . . . in political life. This “second scientific revolution” . . . reflects both a new appreciation of the role of scientific knowledge and a new merger of western organization and scientific skills.¹¹

Professionals in the labor force had risen from 4 percent in 1900, to 8 percent in 1950, to 13 percent in 1966.¹² Daniel Bell predicted that professional and technical workers would reach 15 percent of the labor force by 1975 and might well rise to 25 percent by the year 2000.¹³ “The specialist in his field must be supreme,” as one commentator noted, “for who, other than another similarly qualified specialist, can challenge him?”¹⁴ Even the critics of the professions conceded that it had become impossible to conceive of a modern nation without professions.¹⁵

In the meantime, as the professions geared up to meet the escalating demand for their services, they suffered from overload. In the Daedalus volume, the essay on medicine spoke of the overtaxed physician and of the task of coordinating the proliferating specialties which had arisen out of successful medical research and practice. The essay on science complained of the dangers to scientific professionalism inherent in the bureaucracies which had grown up around scientific research. The distinguished representative of the law stressed the difficulties in maintaining the independence of the bar, the “real problem . . . of making legal services available on a wider basis,”¹⁶ and the problem of managing the “burgeoning mass of data to be assimilated.”¹⁷ The teacher, the military professional, even the politician, expressed similar sentiments. As Kenneth Lynn observed,

It is notable how many of the contributors to this symposium emphasize the multiplicity of demands that are made on the contemporary clergyman, teacher, doctor and scientists.¹⁸

In nearly all articles, the note most sharply sounded was the problem of a success attributed, in Bernard Barber’s words, to the fact that:

the generalized knowledge and the community orientation characteristic of professional behavior are indispensable in our society as we now know it and as we want it to be. Indeed, our kind of society can now maintain its fundamental character only by enlarging the scope for professional behavior.¹⁹

The success of the professionals was thought to be due, in short, to the explosion of the “knowledge industry” whose output it was the function of the professional to apply with rigor, probity, and “community orientation” to the goals and problems of American life.

The only jarring voices in this hymn of confident approbation came from the representatives of divinity and city planning. James Gustafson spoke of “the clergyman’s dilemma.” The clergy, he observed,

retains a loyalty to ancient traditions in thought, in institutional life and practice. Yet it cannot simply rest its case for contemporary validity in its faithfulness to the ancient and honorable paths of the fathers. The overused phrase “the problem of relevance” points to the reality of its dilemma . . .²⁰

And William Alonso spoke of his profession’s “lagging understanding”:

In the past half-century our cities have outgrown our concepts and our tools, and I have tried to show how the lagging understanding of the changes in kind that go with changes in size has led us to try remedies which are unsuited to the ills of our urban areas . . .²¹

Yet in the period between 1963 and 1981, the expression of lagging understandings, unsuitable remedies, and professional dilemmas has become the norm, and the note of triumphant confidence in the knowledge industry is hardly to be heard at all. For in these years, both professional and layman have suffered through public events which have undermined belief in the competence of expertise and brought the legitimacy of the professions into serious question.

The nation had been enmeshed in a disastrous war which had caused it to seem at war with itself. The professional representatives of science, technology, and public policy had done very little to prevent or stop that war or to heal the rifts it produced. On the contrary, professionals seemed to have a vested interest in prolonging the conflict.

A series of announced national crises—the deteriorating cities, poverty, the pollution of the environment, the shortage of energy—seemed to have roots in the very practices of science, technology, and public policy that were being called upon to alleviate them.

Government-sponsored “wars” against such crises seemed not to produce the expected results; indeed, they often seemed to exacerbate the crises. The success of the space program seemed not to be replicable when the problems to be solved were the tangled socio-techno-politico-economic predicaments of public life. The concept of the “technological fix” came into bad odor. Indeed, some of the solutions advocated by professional experts were seen as having created problems as bad as or worse than those they had been designed to solve. Just as urban renewal had emerged in the early sixties as a destroyer of neighborhoods, its unexpected consequences attributed by critics like William Alonso to the weakness of its underlying theory, so in fields as diverse as housing, criminal justice, social services, welfare, and transportation, the most promising solutions, painstakingly worked out and advocated by the experts, came to be seen as problematic.²² They were ineffective, they created new problems, they were derived from theories which had been shown to be fragile and incomplete. To some critics, the public predicaments of the society began to seem less like problems to be solved through expertise than like dilemmas whose resolutions could come about only through moral and political choice.²³

Advocates for peace and for the civil rights of minorities joined forces and turned against the experts whom they saw as instruments of an all-powerful establishment. Around such issues as environmental pollution, consumer exploitation, the inequity and high cost of medical care, the perpetuation of social injustice, scientists and scientifically trained professionals found themselves in the unfamiliar role of villain.

Shortages became gluts. The 1970 census revealed that we had grossly overestimated the demand for teachers, at all levels of our education system. The shortage of scientists and engineers, so visible in the late 1950s, had evaporated by the mid-1960s. Even the much-discussed shortage of physicians began to seem, by the early 1970s, to be less a shortage than an unwillingness on the part of physicians to serve where they were most needed.

With the scandals of Medicare and Medicaid, with Watergate and its aftermath, the public image of the professions was further tarnished. Apparently professionals could not be counted on to police themselves, to live up to standards of probity which set them above the ethical level of the general public. Like everyone else, they seemed ready to put their special status to private use.

Cumulatively, these events not only undermined particular social programs, creating doubts about their underlying strategies of intervention and models of the world, but generated a pervasive sense of the complexity of the phenomena with which scientists and professionals in general were attempting to deal. The events of the mid-1960s and early 1970s eroded the confidence of the public, and of the professionals themselves, that there existed an armamentarium of theories and techniques sufficient to remove the troubles that beset society. Indeed, these troubles seemed, at least in part, attributable to the overweening pride of professional expertise.

In 1982, there is no profession which would celebrate itself in the triumphant tones of the 1963 Daedalus volume. In spite of the continuing eagerness of the young to embark on apparently secure and remunerative professional careers, the professions are in the midst of a crisis of confidence and legitimacy. In public outcry, in social criticism, and in the complaints of the professionals themselves, the long-standing professional claim to a monopoly of knowledge and social control is challenged—first, because professionals do not live up to the values and norms which they espouse, and second, because they are ineffective.

Professionals claim to contribute to social well-being, put their clients’ needs ahead of their own, and hold themselves accountable to standards of competence and morality. But both popular and scholarly critics accuse the professions of serving themselves at the expense of their clients, ignoring their obligations to public service, and failing to police themselves effectively.²⁴ As one observer put it, “the more powerful the’ professions, the more serious the dangers of laxness in concern for public service and zealousness in promoting the practitioners’ interests.”²⁵ Surveys of client populations reveal a widespread belief that professionals overcharge for their services, discriminate against the poor and powerless in favor of the rich and powerful, and refuse to make themselves accountable to the public.²⁶ Among younger professionals and students, there are many who find the professions without real interest in the values they are supposed to promote: lawyers have no real interest in justice or compassion; physicians, in the equitable distribution of quality health care; scientists and engineers, in the beneficence and safety of their technologies.²⁷

Evidence of professional ineffectiveness has been presented in scholarly and journalistic exposés of professionally managed disasters—the Vietnam War, the Bay of Pigs, the nuclear accident at Three Mile Island, the near-bankruptcy of New York City, to name only a few examples of this genre.²⁸ Critics have called attention to the technical expert’s disposition to deploy his techniques, whatever the consequences. Charles Reich, for example, describes the Bureau of Reclamation as “a dam building machine which will keep building dams as long as there is running water in a stream in the United States . . . [without reference to] the values that dams destroy.” He concludes that

professionals . . . can be counted on to do their job but not necessarily to define their job.²⁹

And professionals have been loudly critical of their own failure to solve social problems, to keep from creating new problems, and to meet reasonable standards of competence in their service to their clients. In this vein, Warren Burger recently lashed out at the inadequate preparation and performance of trial lawyers in America, and David Rutstein was only among the first of many physicians to reflect publicly on the failure of the health-care system to keep pace with the enormous expansion of the nation’s investment in medical research and technology.³⁰

Some observers have also noted a trend toward deprofessionalization. Among such diverse professional groups as engineers, teachers, musicians, scientists, physicians, and statisticians, there has been a slackening of the labor market and a decline in economic status and working conditions, a pattern of institutional change which has been variously labelled “bureaucratization,” “industrialization,” or even “proletarianization” of the professions.³¹ Professionals are unionizing in increasing numbers, apparently in recognition of their status as workers in a bureaucracy rather than as autonomous managers of their own careers.

The crisis of confidence in the professions, and perhaps also the decline in professional self-image, seems to be rooted in a growing skepticism about professional effectiveness in the larger sense, a skeptical reassessment of the professions’ actual contribution to society’s well-being through the delivery of competent services based on special knowledge. Clearly, this skepticism is bound up with the questions of professional self-interest, bureaucratization, and subordination to the interests of business or government. But it also hinges centrally on the question of professional knowledge. Is professional knowledge adequate to fulfill the espoused purposes of the professions? Is it sufficient to meet the societal demands which the professions have helped to create?

The crisis of confidence in the professions may not depend solely on the question of professional knowledge. On the other hand, even the muckrakers and radical critics, who emphasize professional self-interest and subordination to class-interest, envisage a purification and restructuring of the professions so that society may gain a fuller, more justly distributed access to the benefits of their special knowledge.³² There remains, even for these critics, the question of the adequacy of professional knowledge to the needs and problems of society.

Let us consider, then, how the crisis of confidence in the professions has been interpreted by professionals who have given serious thought in their own fields to the adequacy of professional knowledge. On the whole, their assessment is that professional knowledge is mismatched to the changing character of the situations of practice—the complexity, uncertainty, instability, uniqueness, and value conflicts which are increasingly perceived as central to the world of professional practice.

In such fields as medicine, management, and engineering, for example, leading professionals speak of a new awareness of a complexity which resists the skills and techniques of traditional expertise. As physicians have turned their attention from traditional images of medical practice to the predicament of the larger health care system, they have come to see the larger system as a “tangled web” that traditional medical knowledge and skill cannot untangle. How can physicians influence a massively complex health care system which they do not understand and of which only a very small fraction is under their direct control?³³ The dean of a major school of management speaks of the inadequacy of established management theory and technique to deal with the increasingly critical task of “managing complexity.”³⁴ The dean of a famous school of engineering observes that the nineteenth-century division of labor has become obsolete. Professionals are called upon to perform tasks for which they have not been educated, and “the niche no longer fits the education, or the education no longer fits the niche.”³⁵

Even if professional knowledge were to catch up with the new demands of professional practice, the improvement in professional performance would be transitory. The situations of practice are inherently unstable. Harvey Brooks, an eminent engineer and educator, argues that professions are now confronted with an “unprecedent requirement for adaptability”:

The dilemma of the professional today lies in the fact that both ends of the gap he is expected to bridge with his profession are changing so rapidly: the body of knowledge that he must use and the expectations of the society that he must serve. Both these changes have their origin in the same common factor—technological change . . . The problem cannot be usefully phrased in terms of too much technology. Rather it is whether we can generate technological change fast enough to meet the expectations and demands that technology itself has generated. And the four professions—medicine, engineering, business management and education—must bear the brunt of responsibility for generating and managing this change. This places on the professional a requirement for adaptability that is unprecedented.³⁶

The role of the physician will be continually reshaped, over the next decades, by the reorganization and rationalization of medical care; the proliferating roles of enterprise will call for a redefinition of the businessman’s role; and architects will have to function in radically new ways as a consequence of the introduction of new building technologies, new patterns of real estate and land development, and new techniques of information processing in design. As the tasks change, so will the demands for usable knowledge, and the patterns of task and knowledge are inherently unstable.³⁷

The situations of practice are not problems to be solved but problematic situations characterized by uncertainty, disorder, and indeterminacy.³⁸ Russell Ackoff, one of the founders of the field of operations research, has recently announced to his colleagues that “the future of operations research is past”³⁹ because

managers are not confronted with problems that are independent of each other, but with dynamic situations that consist of complex systems of changing problems that interact with each other. I call such situations messes. Problems are abstractions extracted from messes by analysis; they are to messes as atoms are to tables and charts . . . Managers do not solve problems: they manage messes.⁴⁰

Ackoff argues that operations research has allowed itself to become identified with techniques, mathematical models, and algorithms, rather than with “the ability to formulate management problems, solve them, and implement and maintain their solutions in turbulent environments.”⁴¹ Problems are interconnected, environments are turbulent, and the future is indeterminate just in so far as managers can shape it by their actions. What is called for, under these conditions, is not only the analytic techniques which have been traditional in operations research, but the active, synthetic skill of “designing a desirable future and inventing ways of bringing it about.”⁴²

The situations of practice are characterized by unique events. Erik Erikson, the psychiatrist, has described each patient as “a universe of one,”⁴³ and an eminent physician has claimed that “85 percent of the problems a doctor sees in his office are not in the book.”⁴⁴ Engineers encounter unique problems of design and are called upon to analyze failures of structures or materials under conditions which make it impossible to apply standard tests and measurements.⁴⁵ The unique case calls for an art of practice which “might be taught, if it were constant and known, but it is not constant.”⁴⁶

Practitioners are frequently embroiled in conflicts of values, goals, purposes, and interests. Teachers are faced with pressures for increased efficiency in the context of contracting budgets, demands that they rigorously “teach the basics,” exhortations to encourage creativity, build citizenship, help students to examine their values. Workers in the fields of social welfare are also torn between a professional code which advocates attention to persons and bureaucratic pressure for increased efficiency in processing cases. School superintendants, industrial managers, and public administrators are asked to respond to the conflicting demands of the many different groups which hold a stake in their enterprises. Professionals engaged in research and development are not infrequently torn between a “professional” concern for technological elegance, consumer safety, or social well-being, and an institutional demand for short-term return on investment.

In some professions, awareness of uncertainty, complexity, instability, uniqueness, and value conflict has led to the emergence of professional pluralism. Competing views of professional practice—competing images of the professional role, the central values of the profession, the relevant knowledge and skills—have come into good currency. Leston Havens has written about the “babble of voices” which confuses practitioners in the field of psychotherapy.⁴⁷ Social workers have produced multiple, shifting images of the nature of their practice, as have architects and town planners.⁴⁸