Why primary care is so damn frustrating?

"We have seen how the doctors’ mindlines are a social construct. But the patient’s
views are of course also a social construct – he or she will have acquired them
through their life experience, their family history, their friends, their reading, their
exposure to media discussions of depression and so on, and these in turn may be
influenced by wider forces such as the views of politicians, psychiatrists, celebrities,
the pharmaceutical industry, self-help and other books, and so forth. He or she has
acquired their view of the disease through what Berger and Luckmann (1966) call
the ‘primary socialization’ of general upbringing and social experience (p. 173).
That construct is derived through its own elaborate web of actors and interactions,
equivalent to that of the Heartshire actor-network example (Box 9.1), and is
shared among their own communities of practice – for example of family, friends
and neighbors who have experienced similar problems."

Practice-based Evidence for Healthcare: Clinical Mindlines

By John Gabbay, Andrée le May

The Different Avatars of disease

Why does it take so many years beforeMedicine changes ?

 For example CHF (Congestive Heart Failure)

People engage in the rhetorical process anytime they speak or produce meaning. Even in the field of science, the practices of which were once viewed as being merely the objective testing and reporting of knowledge, scientists must persuade their audience to accept their findings by sufficiently demonstrating that their study or experiment was conducted reliably and resulted in sufficient evidence to support their conclusions.
Wikipedia

It is 1997. The hearts Of 10 per cent Of elderly people in the UK are failing
to pump blood effectively. Doctors manage them With established
methods such as diuretics (costing the NHS over 60m pounds per year). Drug
companies am producing new ACE inhibitors. Inventors and Wikipedia
manufacturers a new kind of instrument (echocardiographs) for
measuring heart failure that can help guide the use of ACE inhibitors.
Researchers (with the help of research funders, industry, health service
providers, patients, universities, journals) show that the use Of these new
techniques unquestionably improves care. Department of Health civil
servants, anxious to meet political targets and demonstrate NHS
improvements, call on national/ opinion leaders to endorse the research
findings to guide improvements in practice. Royal colleges, R&D centres
and medical journals am strongly promoting evidence-based practice. The
resulting guidelines and exhortations to a large extent fall on deaf ears;
many GPs cavil at such external interference, But they are coming round
to the idea that clinical audit —still in 1997 seen warily by many doct01S
as a suspect innovation — is a Good Thing. Audits are showing that some
patients do well on old-fashioned diuretics but some continue to die
unnecessarily. The NHS management hierarchy exerts pressure through
performance targets for improving the proper use of the new drugs.
Meanwhile public health doctors in Heartshire, anxious to assert their
role in improving health, produce a document showing that thousands of
life years might be gained locally by conforming to the new guidance.
Cardiologists the Heurlshire Hospital are mightily frustrated by the
lack of action to set up a much nccdcd  echocardiography scericc. Local
GP opinion leaders argue for two main changes to combat serious defects
in services for people with heart failure: (1) use more ACE inhibitors and
(2) establish an open echocardiography service directly accessible to GPs.
Others argue that echocardiography should be obtained only through
cardiology out-patients. Those keen to improve the service begin to
examine the research evidence closely and find little clarity about
clinically important details such as the dosages of ACE inhibitors or the
Echocardiographic criteria

What is the problem with evidence-based medicine?

 Why do you think Evidence based medical guidelines SUCK?

This is best described in the foreword to

Practice-based Evidence for Healthcare: Clinical Mindlines

By John Gabbay, Andrée le May

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

Is medicine really a science ?

Medicine has avoided facing a harsh reality. Although we assume that medical decisions are driven by established scientific fact, even a cursory review of practice patterns shows that they are not. Angioplasty became a multibillion-dollar industry long before a single randomized trial or epidemiologic study had shown its benefits [1]. Large numbers of MRI units were purchased during the first 5 years of their clinical availability, before any data were available to show that MRI was preferable to the diagnostic alternatives [2]. Also, although randomized trials have proved the lifesaving value of mammography only in women over 50 years of age [3], the American College of Radiology advises that women begin receiving regular testing at 40 years of age.

What do Bees see in the sky

We humans  enjoy blue skies but  an insect like the Honeybee sees much more.

  Light scattered in a blue sky forms a characteristic pattern of partially polarized light which is dependent on the position of the sun and invisible to human eyes. With a UV receptor in each of the lens units of a compound eye, and a UV filter oriented differently in each of these units, a bee is able to detect this polarization pattern. A small piece of blue sky is enough for a bee to recognize the pattern changes occurring over the course of a day. This provides not only directional but also temporal (Time)information.

Other interesting facts 

Bees have an internal clock with three different synchronization or timekeeping mechanisms. If a bee knows the direction to a feeding place found during a morning excursion, it can also find the same location, as well as the precise time at which this source provides food, in the afternoon, based on the position of the sun.^[10]
Based on the magnetic field, the alignment of the plane of a honeycomb under construction (e.g., the new honeycomb of a swarm) will be the same as that of the home hive of the swarm, according to Frisch. By experiment, even deformed combs bent into a circle can be produced.
The vertical alignment of the honeycomb is attributed by Frisch to the ability of bees to identify what is vertical with the help of their head used as a pendulum together with a ring of sensory cells in the neck

Psychoactive Plants: Ethnopharmacology and Its Applications

Acacia, Aconitum, Acorus, Agave,
Anadenanthera, Areca, Argemone,
Ariocarpus, Artemisia, Arundo, Atropa
Alstonia,
Argyreia,
Banisteriopsis, Boswellia, Brugmansia, Brunfelsia
Caloea, Calliandra, Camellia, Cannabis, Carnegia,
Catha, Cestrum, Cinnamomum, Coffea, Cola, Coleus,
Convolvulus, Corynanthe, Coryphantha, Cytisus
Datura, Desfontainia, Diplopterys, Duboisia
Echinops, Ephedra, Erythrina, Erythroxylum, Escholzia
Heimia, Humulus, Hyoscyamus
Ilex, lochroma, Ipomoea
Juniperus, Justicia
Lactuca, Latua,
Ledum,
Leonurus,
Lolium,

Lonchocarpus, Lophophora
Mammillaria, Mandragora, Mesembryanthemum,
Mimosa, Mitragyna, Mucuna, Myristica
Nicotiana, Nuphar, Nymphaea
Pachycereus,
Papaver,
Passiflora, Paullinia,
Pausinystalia, Peganum, Pelecyphora, Petroselinum,
Phalaris, Phragmites, Phytolacca, Piper, Psidium,
Psychotria
Rhynchosia
Salvia, Sassafras, Sceletium, Scopolia, Solandra,
Solanum, Sophora, Strychnos
Tabernaemontana, Tabernanthe, Tagetes, Tanaecium,
Theobroma, Trichocereus, Turbina, Turnera
Vaccinium, Veratrum, Virola, Vitis
Withania

From

The Encyclopedia of Psychoactive Plants: Ethnopharmacology and Its Applications

By Christian Rätsch