Why do you think Evidence based medical guidelines SUCK?
This is best described in the foreword to
Common sense is, unfortunately, not always common. Such is the case,
I'm afraid, in much of the academic work done over the last twenty years
to understand the of research by healthcare practitioners. For the
decisions we make in our everyday lives — whom to marry, what house
or car to purchase, which movies to see, where to go on holiday — we
know that we're heavily influenced by our social and cultural context.
It's common sense that things like the friends with whom we socialize,
our access to financial and other resources, our family history, our self-
image, our previous experiences in the area (negative and positive) are
used to interpret whatever 'hard evidence' we collect to decide on a
course of action. Why should we believe that the situation is any
different for healthcare practitioners making daily clinical decisions?
Yet the academic world has largely ignored these social and cultural
influences when assessing clinical guideline implementation or, more
generally, the application of research evidence to decisions in healthcare.
The (largely implicit) assumption seems to be that healthcare
practitioners ought to be dispassionate, rational, probabilistic decision
makers and, therefore, we will proceed as if that is the case. 'Ille classic
confusion of ought with is. Hence researchers design interventions such
enhanced educational opportunities, more readily accessible formats
for guidelines, payment incentives and even just-in-time reminders that
assume there is a rational, probabilistic decision maker at the receiving
end. Sometimes these interventions do actually work to squeeze the
research into the decision, but more Often than not they don't. When they
don't we decry the practitioner's lack of commitment rather than the
researcher's lack of common sense.
The p10blem as I see it is that most researchers have been less
interested in helping the practice world do its work better and more
interested in getting their own product — research — used by that world.
For too long the evidence-based movement has been more about
marketing research, being a shill for the academic community, than about
understanding where and how research evidence can help practitioners. I
do not believe that this has been a wilful misdirection of effort, just a
particularly stark example of a common phenomenon — we all tend to
believe Chat what we do is more important/valuable/relevant (insert your
laudatory adjective of choice) than what they do.
How, then, do practitioners actually decide on courses of action? If
they don't behave how we think they ought to, what is their modusoperandi?
And, given the answer to this, what kinds of interventions will
therefore help them by improving the profile Of research in their
decisions? Note that the goal here is not for the imperial forces of
research to vanquish all other inputs. Rather it is to have the role of
research optimized in the context of other perfectly reasonable
considerations — such as patients' preferences or local colleagues'
experiences — and the cognitive processes clinicians actually use to make
their decisions.
These are the issues addressed in the following pages. A text that
brings common sense to the complex interaction between Ought and is in
healthcare practitioner behaviour. As the title makes clear — Practice-
based Evidence — the book starts a desire to better understand
the practice environment and then works those insights back to
implications for the research environment, rather than the more usual
reverse pathway.
At the core is the concept of mindlines. These exist at the level of an
individual clinician and pragmatically 'blend formal, informal, tacit and
experiential evidence into his or her main signposts for action. 'l'hey
draw on collective mindlines done at the level of practices or other larger
social groupings. The book uses the authors' ethnographic work as well
as other literature to describe the origins and ongoing feedstock for
these mindlines, how they evolve and in response to what inputs, how
they ale used, how they are adapted to changing contexts and even how
they relate to existing cognitive and social theory. In other words, the
book provides a practical guide for how a clinician is making decisions
and, thervf01V, how research might become a more relevant part Of the
process.
The wide range of sources that the book draws upon includes work
from the business literature by Brown and Duguid (2000) which
highlights 'the social life of information'. Central to the book is this
emphasis on the social processes used to transform and
exchange information. This approach does not start by privileging
research over other sources, although it does provide insights into how
this might be better accomplished. One clear implication is that if we
really want to know how to create and apply clinically useful knowledge
from academically produced research it is time for the social scientists to
eclipse the clinical trialists. In future studies of clinical behaviour change
we should be more likely to employ the tools Of psychology and
sociology than those of clinical epidemiology and bio statistics.
I first encountered this work through Gabbay and le May's original
article on mindlines in a 2004 issue of the British Medical Journal
(Gabbay and le May 2004). I was excited. Indeed, I immediately put pen
to paper (actually, skin to keyboard) to communicate my excitement to
the authors. A correspondence ensued in which I was astounded to find
out that they had come up with the concept of mindlines without ever
having heard Of the remarkable songlines Of Australian aboriginals. Upon
reading their article I had felt stile they must have read the travel writer
Bruce Chatwin' s brilliant exposition on the topic (Chatwin 1998 [1987]).
My astonishment was because Of the obvious parallels in the functions
Of these two kinds Of 'lines'. Among Other functions the songlines (also
known as 'dreaming tracks') are navigation tools for the outback. They
guide aboriginals from one landmark to another and, when combined
with songlincs 'borrowed' from other tribes, can Lake travelers from one
end of the country to the other. Aboriginals use them as fuzzy boundaries
to demarcate one territory from another in what are often ambiguously or
subtly featured outback landscapes.
With a slightly less romantic turn Of phrase one could imagine using a
similar description to capture what Gabbay and le May have identified in
similar description to capture what Gabbay and le May have identified in
this book as clinical mindlines. Indeed, in Chapter 2 they expand on this
parallel, highlighting the idca of what I would call a navigation device
that one might use to negotiate the lowlands and highlands, across the
rivers and lakes, and between the swamps and terra firma of the clinical
landscape.
By uncovering this concept of mindlines the authors have pointed the
evidence-based practice movement in what should prove to be a rnorv
profitable direction. They have not only shown us the kinds Of maps
clinicians actually use, but also given us insights into their map-making
techniques, With this in hand researchers and policy makers should be in
a better position to interact meaningfully with the practice-based world.
Jonathan Lomas
Former CEO, Canadian Health Services Research Foundation
Ottawa, Canada
April 2010
This is best described in the foreword to
Common sense is, unfortunately, not always common. Such is the case,
I'm afraid, in much of the academic work done over the last twenty years
to understand the of research by healthcare practitioners. For the
decisions we make in our everyday lives — whom to marry, what house
or car to purchase, which movies to see, where to go on holiday — we
know that we're heavily influenced by our social and cultural context.
It's common sense that things like the friends with whom we socialize,
our access to financial and other resources, our family history, our self-
image, our previous experiences in the area (negative and positive) are
used to interpret whatever 'hard evidence' we collect to decide on a
course of action. Why should we believe that the situation is any
different for healthcare practitioners making daily clinical decisions?
Yet the academic world has largely ignored these social and cultural
influences when assessing clinical guideline implementation or, more
generally, the application of research evidence to decisions in healthcare.
The (largely implicit) assumption seems to be that healthcare
practitioners ought to be dispassionate, rational, probabilistic decision
makers and, therefore, we will proceed as if that is the case. 'Ille classic
confusion of ought with is. Hence researchers design interventions such
enhanced educational opportunities, more readily accessible formats
for guidelines, payment incentives and even just-in-time reminders that
assume there is a rational, probabilistic decision maker at the receiving
end. Sometimes these interventions do actually work to squeeze the
research into the decision, but more Often than not they don't. When they
don't we decry the practitioner's lack of commitment rather than the
researcher's lack of common sense.
The p10blem as I see it is that most researchers have been less
interested in helping the practice world do its work better and more
interested in getting their own product — research — used by that world.
For too long the evidence-based movement has been more about
marketing research, being a shill for the academic community, than about
understanding where and how research evidence can help practitioners. I
do not believe that this has been a wilful misdirection of effort, just a
particularly stark example of a common phenomenon — we all tend to
believe Chat what we do is more important/valuable/relevant (insert your
laudatory adjective of choice) than what they do.
How, then, do practitioners actually decide on courses of action? If
they don't behave how we think they ought to, what is their modusoperandi?
And, given the answer to this, what kinds of interventions will
therefore help them by improving the profile Of research in their
decisions? Note that the goal here is not for the imperial forces of
research to vanquish all other inputs. Rather it is to have the role of
research optimized in the context of other perfectly reasonable
considerations — such as patients' preferences or local colleagues'
experiences — and the cognitive processes clinicians actually use to make
their decisions.
These are the issues addressed in the following pages. A text that
brings common sense to the complex interaction between Ought and is in
healthcare practitioner behaviour. As the title makes clear — Practice-
based Evidence — the book starts a desire to better understand
the practice environment and then works those insights back to
implications for the research environment, rather than the more usual
reverse pathway.
At the core is the concept of mindlines. These exist at the level of an
individual clinician and pragmatically 'blend formal, informal, tacit and
experiential evidence into his or her main signposts for action. 'l'hey
draw on collective mindlines done at the level of practices or other larger
social groupings. The book uses the authors' ethnographic work as well
as other literature to describe the origins and ongoing feedstock for
these mindlines, how they evolve and in response to what inputs, how
they ale used, how they are adapted to changing contexts and even how
they relate to existing cognitive and social theory. In other words, the
book provides a practical guide for how a clinician is making decisions
and, thervf01V, how research might become a more relevant part Of the
process.
The wide range of sources that the book draws upon includes work
from the business literature by Brown and Duguid (2000) which
highlights 'the social life of information'. Central to the book is this
emphasis on the social processes used to transform and
exchange information. This approach does not start by privileging
research over other sources, although it does provide insights into how
this might be better accomplished. One clear implication is that if we
really want to know how to create and apply clinically useful knowledge
from academically produced research it is time for the social scientists to
eclipse the clinical trialists. In future studies of clinical behaviour change
we should be more likely to employ the tools Of psychology and
sociology than those of clinical epidemiology and bio statistics.
I first encountered this work through Gabbay and le May's original
article on mindlines in a 2004 issue of the British Medical Journal
(Gabbay and le May 2004). I was excited. Indeed, I immediately put pen
to paper (actually, skin to keyboard) to communicate my excitement to
the authors. A correspondence ensued in which I was astounded to find
out that they had come up with the concept of mindlines without ever
having heard Of the remarkable songlines Of Australian aboriginals. Upon
reading their article I had felt stile they must have read the travel writer
Bruce Chatwin' s brilliant exposition on the topic (Chatwin 1998 [1987]).
My astonishment was because Of the obvious parallels in the functions
Of these two kinds Of 'lines'. Among Other functions the songlines (also
known as 'dreaming tracks') are navigation tools for the outback. They
guide aboriginals from one landmark to another and, when combined
with songlincs 'borrowed' from other tribes, can Lake travelers from one
end of the country to the other. Aboriginals use them as fuzzy boundaries
to demarcate one territory from another in what are often ambiguously or
subtly featured outback landscapes.
With a slightly less romantic turn Of phrase one could imagine using a
similar description to capture what Gabbay and le May have identified in
similar description to capture what Gabbay and le May have identified in
this book as clinical mindlines. Indeed, in Chapter 2 they expand on this
parallel, highlighting the idca of what I would call a navigation device
that one might use to negotiate the lowlands and highlands, across the
rivers and lakes, and between the swamps and terra firma of the clinical
landscape.
By uncovering this concept of mindlines the authors have pointed the
evidence-based practice movement in what should prove to be a rnorv
profitable direction. They have not only shown us the kinds Of maps
clinicians actually use, but also given us insights into their map-making
techniques, With this in hand researchers and policy makers should be in
a better position to interact meaningfully with the practice-based world.
Jonathan Lomas
Former CEO, Canadian Health Services Research Foundation
Ottawa, Canada
April 2010
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