Professionals are under siege. Their one-time autonomy is no longer sacrosanct, partly because patients and clients are more knowledgeable and partly because they are more suspicious. Even doctors, who have for so long inhabited the higher slopes of exclusivity, find their patients challenging their judgement, even as far as the court room.

The professions themselves have reacted in various ways, from truculence to anxiety, and the insistence that everything has to be proved has not helped those professionals who feel that at the heart of their practice is something largely invisible but fundamentally important - judgement.

The two principal authors of this book believe that professional judgement 'contains a major element of artistry'. Professional practice is complex and often deals with uncertainties which can only be understood through the use of expertise, common sense, past experience, and even intuition. The protocols, of which managers and government are so enamoured, are often opposed by professionals because such rules and procedures cannot deal with uncertainty, and because they reduce competence to a mere display of competencies.

The authors contrast the technical rational approach (TR) with professional artistry (PA). TR concentrates on processes leading to measurable outcomes, but PA also includes the inputs, the values and the principles which govern us all even when we do not declare them. Given all this, how can professionals continue to meet the needs of their patients and how can those patients be assured that they will be treated right? The book chooses case studies to explore the issue. But these are not hypothetical case studies; each one is an account of a critical incident in the professional lives of a doctor, three nurses, a physiotherapist and an occupational therapist. It is perhaps a pity that only one of the subjects is directly involved in patient care even if the issues of professionalism are well enough illustrated by those involved in the training of professionals.

Academics worry whether using autobiographical material is valid: surely this will lead to undue subjectivity and invalidate any conclusions? The authors have little time for such objections and make a strong case for the 'insider researcher' who is able to bring personal theory to mediate more formal theories. Certainly, much academic objectivity is utterly bogus: we all come from somewhere, and that experience shapes our thinking.

The six case studies are written up by the people involved. It says much for their courage that they are able to be so frank about what were for most of them, at least initially, negative experiences. But that is exactly the authors' point: the contributors demonstrate the process of professional development as they try to make sense of what has happened to them. From the rawness of the actuality, through reflection to critical appreciation, they all come out the other end wiser and, we must assume, better professionals.

The last two parts of the book are the authors' reflections and interpretations of what the case studies have shown. Fundamentally, they point out that professional judgement is a continuum: what I do - intuitive; what I might do - strategic; what I could do - reflective; and what ought I to do now - deliberative. One could also add: what I should do - ethical.

This is a challenging and timely book for all professionals and those who work with them. For the former, it should help to restore some of their confidence, and for the rest of us, help us to value what we cannot describe but what we nearly always recognise - good professional judgement.


Visiting senior fellow at Birmingham University's health services management centre.