Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7473.1013 (Published 28 October 2004) Cite this as: BMJ 2004;329:1013
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I enjoyed the article of Gabbay and le May as they put into focus the
“processes of collective “sense making” by which knowledge, both explicit
and tacit and from whatever sources, is negotiated, constructed, and
internalised in routine practice.” They identified mindlines replacing
guidelines in daily practice.
If we assume that these processes of collective sense making are
shaped by, among other factors, culture and training, it would be
interesting to see, if the social construct of mindlines will be a valid
approximation for other countries as well. My hypothesis for Germany would
be that a similar study would reveal neither mindlines nor other linear
structures.
Instead of the linear, algorithm-driven process commonly used in
Anglo-Saxon practice, the process of diagnosing in Germany might better be
described as an adjusting of memorised disease patterns to clinical
pictures of the patients. The experience of a doctor is reflected by an
increased number of actively retrievable disease patterns. The linguistic
equivalent would be the term Krankheitsbild, which could be literally
translated as “disease image” rather than “clinical picture” and is
thought of representing the essential character of a disease rather than
the mere symptoms. Krankheitsbilder are structuring lecture series for
medical students and seem to shape the structure that underlies clinical
thinking in Germany.
Acknowledging that this is still a mind game: to overcome the deep-
rooted resistance against evidence based medicine in Germany clinical
practice would need to win minds and hearts. Accepting that the
predominating “processes of collective sense making”, namely adjusting
disease patterns with clinical pictures, might not be fully compatible
with following linear algorithm-oriented guidelines would be a first step.
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Place of work (lack of space in the corresponding box)
Department of Epidemiology, Social Medicine, and Health System Research,
Hannover Medical School,
30623 Hannover,
Germany
Competing interests:
None declared
Competing interests: No competing interests
Gabbay’s important study of how primary care practitioners decide and
use knowledge identifies a polarisation in healthcare research and
development. On the one hand are those that see healthcare as a linear
system that can be understood by a reduction into its component parts and
where there is a simple relationship between cause and effect. On the
other, there are those who see the system as inherently complex, where
input and output relationships are uncertain but patterns emerge that
could not be predicted on the basis of analysis of the underlying parts.
Although the field is in its infancy, non-linear systems theory is
beginning to offer new approaches to investigating complex systems (1)
(2). The trick is to match the analytical approach to the complexity of
the system under study. Complex environments need regulatory systems that
match their complexity. The current modernisation agenda reflects a
reductionist approach which inhibits the developments of mindlines and
mindfulness which is detrimental to the evolution of system.
Yours faithfully
David Kernick
References:
1. Kernick D (Editor). Complexity and Healthcare Organisation.
Abingdon: Radcliffe Medical Press, 2004.
2. Papadopoulous MC, Hadjitheodossiou M, Chrysostomou C, Hardwidge
C, Bell BA. Is the national health service at the edge of chaos?
Journal of the Royal Society of Medicine 2001;94(12):613-16.)
Competing interests:
None declared
Competing interests: No competing interests
Its clearly time to change the EBM label to "evidence informed
practice". Though EBMers have stressed the importance of patient values
and patient context in decision making, this is missed in most
discussions. So that evidence is not displaced by mutant memes on the
excuse that evidence ignores values and context (it doesn't), I suggest we
are now in the era of EIM not EBM.
I imagine patient's would be either puzzled or concerned by this
article and the subsequent discussion. When I am a patient, I would like
the (shared) decision making in the consultation to be informed by current
best evidence for my condition. That doesn't mean a slavish obediance to
RCT results. It means that good evidence forms part of the discussions. I
would like to know what good evidence I might be potentially ignoring so
that I can an informed decision: as either patient or doctor.
The "mindlines" described accord with what I see - and may be helpful
if they enrich the context of evidence (problems to watch out for or tips
for doing the intervention). But the mindlines and memes are of concern if
they supply counterfeit evidence: bad money drives out good money. Some
recent mindlines and memes include HRT, bed rest for almost anything, and
extraction of asymptomatic wisdom teeth. So a puzzle remains: how do we
get valid memes into the mindlines while not driving out the wisdom of
experience? I suggest we start with EIM and add a little wisdom.
Competing interests:
Director, the Centre for Evidence-Based Medicine, Oxford (which may have to change its name).
Competing interests: No competing interests
There are those extremists who believe EBM (actually external
evidence) is the ultimate solution to all problems - and they are morons.
And then there are other extremists who believe external evidence has no
place, and their own experience and the "art" of medicine is all that
counts - and they are also morons (and probably a little lazy to bother
with anything as mundane as evidence).
Thankfully (at least for the patients), most practitioners walk the
middle road and appreciate that EBM is yet another tool in the bag of a
reflective practitioner. Such practitioners understand that being able to
track down and evaluate evidence may benefit some of their patients. They
also appreciate that EBM is explicitly about tailoring external evidence
to an INDIVIDUAL PATIENT'S VALUES AND PREFERENCES with the aid of the
practitioner's CLINICAL JUDGEMENT. They are puzzled when 1) external
evidence, 2) clinical judgement, and 3) patient's feelings are presented
by the moron minority as mutually exclusive! And many proponents of EBM
that I have been fortunate to come across belong to this humble group that
puts patients at the centre of the practice while keeping a keen eye on
the evidence to ensure that their patients get the best of what is good
for them, where "what is good for them" is defined by none other than the
patient.
Competing interests:
I have no affiliation to any extremist groups.
Competing interests: No competing interests
I read with interest the paper from J Gabbay and A le May, as well as
the learned discussion on memes that followed. Gabbay's and le May's
mindlines relate to what many of us have instinctively known all along:
why we do not slavishly follow guidelines and the EBM mantra. Certainly
GPs have been fortunate for many years in having some degree of autonomy
in relation to prescribing and management. This autonomy is gradually
being eroded and I am sure that the 'New UK Contract' is playing a huge
part in this evolution.
I remember years ago as a GP trainee being surprised that the time of
the week could influence whether a GP prescribed antibiotics or not for a
sore throat. Friday evenings you were more likely to obtain your
penicillin in the hope that this would deter you from attending the
Saturday morning 'emergency' surgery. Learning from experience certainly.
Similarly I am less likely to prescribe drug X again if the first
person who received it from me developed some sort of reaction...yes we
all recognise our trials of one.
Are these memes? I pass this knowledge onto students and GP
registrars as a stimulus for discussion of the difficulties of truly
practising an evidence-based approach. But one of the major factors in my
decision making is now my patients' decisions. Shared decision making
relies on communication and definition of risk, but patients are not
always logical people and their health beliefs and values may cause them
to make a decision totally at variance with the way I expected them to
choose. Patients may wish to have evidence but they also want to believe
in what doctors would label the non-orthodox. Witness the popularity of
complementary medicine and the lack of RCTs relating to its strategies.
This does not deter patients and I have also come across patients for whom
these alternative approaches have helped in contrast to our often adverse
reaction-laden Western drugs.
We do change our practice. Look at changes in drug prescribing over
the last decade: the inexorable rise of the PPIs and statins. What
influences us? It is a complex issue as 'mindlines' suggest.
Competing interests:
None declared
Competing interests: No competing interests
Madam: Des Spence has coined a new concept 'moron medicine'; hope he
does not offend the legitimate and proud bearers of this title.
If one cares to search the Cochrane Collaboration of Systematic
Reviews under Wahlbeck's update on evidence-based clozaril treatment in
schizophrenia, he/she would find out the following paragraphs: 'This
systematic review confirms that clozapine is convincingly more effective
than typical antipsychotic drugs in reducing symptoms of schizophrenia,
producing clinically meaningful improvements and postponing relapse [...]
The effects of clozapine in comparison to conventional neuroleptics in
hospitalised adults is now well established and the conduct of further
hospital-based short-term trials would be a waste of resources.'
http://www.update-software.com/abstracts/ab000059.htm
It appears that the gold standard treatment of schizophrenia would
naturally be clozaril as indicate by the excellent reviews and confirmed
by clinical practice. If EBM rules supreme, the natural question would
be: why clozapine remains a reserve drug mainly used in the treatment
resistant schizophrenia? One can argue that the potentially lethal side
effects i.e. agranulocytosis, sudden death, etc would compel us to use the
common-sense as opposed to using EBM. This dilemma raises a number of
questions:
1) Based on EBM, should everyone newly diagnosed with schizophrenia
be entitled to receive the gold standard treatment?
2) Should one use the common-sense and ignore the EBM in view of the
potential lethal side-effects?
3. Is a potential shorter life span with full insight an acceptable
alternative as opposed to a longer life span without full insight?
Competing interests:
None declared
Competing interests: No competing interests
In our practice we have coined the phrase “moron medicine”. This
unfortunately refers largely to our hospital colleagues ( although an
number of GPs are also guilty) who grandiosely make reference to research
paper or plethora of guidelines in their correspondence. Now this might
seem a little harsh, as perhaps we might be the ignorant “morons”.
The problem, however, is that these colleagues take this “evidence”
as rigid hard fact without any understanding about the limitations of the
evidence and the bloated NNTs. But the real “no-brainer” is the lack of
understanding of the context of the individual patient. I see frail
elderly patients getting the “best treatment” by being prescribed 10
medications but unable to even access home help services.
Ten years ago I was drunk on the spirit of EBM but the longer I
indulged the more I saw the extensive flaws of much of this “evidence”. I
eventually awoke with a terrible sense of self-pity and a feeling “what
have I done”. EBM must be seen as useful but simplistic tool to aid care
and will never be a substitute for experience or continuity.
I hope GPs continue use their judgement and ignore some of the
“evidence” for the sake of their patients. The new GMS contact,
unfortunately, is undermining these judgements. We will soon be replaced
with fast food workers flogging homogeneous “super-size combo health
deals.”
Competing interests:
None declared
Competing interests: No competing interests
Mindlines are defined by Gabbay and le May as, "collectively
reinforced, internalised tacit guidelines, which were informed by brief
reading, but mainly by their interactions with each other and with opinion
leaders, patients, and pharmaceutical representatives and by other sources
of largely tacit knowledge that built on their early training and their
own and their colleagues' experience"..."Mindlines were iteratively
negotiated with a variety of key actors, often through a range of informal
interactions in fluid "communities of practice," resulting in socially
constructed "knowledge in practice." (1). That's a Monty Pythonesque
parody of aquisition of medical memes and meme complexes in general
practice. The same comments could apply to hospital practice. .
A meme has been defined as "Richard Dawkins's term for an idea
considered as a replicator, especially with the connotation that memes
parasitise people into propagating them much as viruses do.
Memes can be considered the unit of cultural evolution. Ideas can
evolve in a way analogous to biological evolution. Some ideas survive
better than others; ideas can mutate through, for example,
misunderstandings; and two ideas can recombine to produce a new idea
involving elements of each parent idea.
The term is used especially in the phrase "meme complex" denoting a
group of mutually supporting memes that form an organised belief system,
such as a religion. However, "meme" is often misused to mean "meme
complex""(2).
An example of a medical memes might be the mental response to
hypotension. It is intuitively interpreted as shock and having a poor
prognosis unless the appropriate meme complex is set in motion. In the
case of haemorrhagic shock, for example, the evidence of blood loss would
automatically initiate the meme complex of inserting an IV, giving fluids,
crossmatching and possibly giving blood. In cardiogeneic shock the
evidence of acute myocardial disease might automatically initate the meme
complex of ECG monitoring, inserting an IV. managing arrhythmias, and
possibly giving oxygen, red cells and inotropes to improve cardiac output
and oxygen dispatch to the tissues.
The meme complex are specialty dependent. In the case of obstructive
jaundince, for example, a physician or radiologist might have as their
goal making a definitive diagnosis and/or improving thejaundice by
achieving biliary drainage by percutaneous or endoscopic means. A
specalist heptaobiliary surgeon has a completely different goal and hence
meme complex(3). A common reason for this difference is that the ultimate
goal of the physician/radiologist is to refer the patient to a generic
surgeon days or a week or two later when an histological diagnosis has
been made and the jaundice is improving. The meme of a skilled hepato-
bilary surgeon is to provide a definitive and permanent solution to the
mechanical problem. THis/her meme complex would include receiving the
patient very much earlier in the course of their disease [ideally in the
same hour that the diagnosis of obstructive jaundince is made] without the
pitch having been queered by invasive interventions.
It is important to define memes and the meme complexes or mindlines
evolved from them for many meme mutations have occurred in medical
practice and may be responsible for the evolution of ineffective and even
harmful meme complexes. The different meme complexes that have evolved in
physicians/radiologists/surgeons in the case of obstructive jaundice are
cases in point. A better example may be hypotension which in the case of
haemorrhagic shock (4) and possibly even in cardiogenic (5) and septic
shock might be better managed if clinicians were to optimise tissue
energetics by accepting the hypotension, not giving oxygen, retricting IV
fluids and/or even witholding inotopes (6). That is the antithesis of most
existing meme complexes.
Medical memes and meme complexes or mindlines are almost exclusively
dependent upon our understanding of pathophysiology, many physicians and
radiologists being completely unaware of the pathophysiological pitfalls
in the meme complexes the have evolved for managing obstructive jaundince.
The reverse may also be true, some endocrinologists for example claiming
that many thyroid operations are being performed unnecessarily with
harmful consequences. The list is endless.
Nothing in my experince has done more to change my thinking of the
medical landscape and expose the presence of possibly harmful mutations in
memes and meme complexes than the realisation of the pivotal importance of
tissue energetics in the pathophysiology of and outcome from most common
acute and chronic diseases(7). Hence my claim that we have been
worshipping false gods and need to be worshipping new ones(8).
Many of our most cherished meme complexes, such as administring
oxygen, raisng blood pressure with iv infusions of fluid and/or inotropes
in hypotensive patients, may be ineffective or even harmful mutations. A
good place to begin in rectifying what would seem to be a massive but
largely unppreciated problem would be to establish a list with definitions
of all existing medical memes and meme complexes. The list of memes is not
going to be long, vital signs being the most basic memes but aruably all
being mutated memes. The next step would be to define ineffective and
harmful mutations and to eradicate them.
New memes, such replacing vital signs with monitoring tissue pCO2/pH,
and meme complexes, conceivably such as the witholding of oxygen and
fluids in hypotensive patients, could then evolve. This could transform
the practice of medicine ovrnight to a degree that ultimately renders
existing practices historic relics analogous to blood letting and heating
mental patients in hot baths.
I see no place for the evidence base derived from prospective
randomised studies in defining existing memes and meme complexes or in
identifying meme mutations. Moreover the data derived from any prospective
randomised study that has used a mutated meme, such as a change in blood
pressure, cardiac output, oxygen dispatch or risk-factor, as an end-point
could become meaningless. More importantly any study that has incorporated
mutated meme complexes in routine managment could become uninterpretable.
Indeed it could be argued that even those studies that have used mortality
or disability-adjusted life-years as end-points but have incorporated
mutated meme complexes in routine care should be repeated.
Monoclonal antibodies to endotoxin might have had little effect upon
outcome in prospective randomised studies and be considered cost-
ineffctive (9) but the trials may have incorporated matutated memes and
meme complexes. That is to say that the magic bullet may not have been
used appropriately. Used in a different way it could be so effective that
any form of prospective controlled study is rendered unethical. Indeed the
information I received from a mindline, a personal communication about a
single patient received from a prnciple investigator, indicated just
that. In short defining memes, meme complexes and identifying mutated
memes may be a much more logical, effective, cheaper and more rapid way of
evolving patient care than evidence base medicine.
1. John Gabbay and Andrée le May
Evidence based guidelines or collectively constructed "mindlines?"
Ethnographic study of knowledge management in primary care
BMJ 2004; 329: 1013-0
2. MEME - Definition. www.hyperdictionary.com/dictionary/meme
3. Biopsy of potentially operable hepatic colorectal metastases is
not useless but dangerous
Oliver M Jones, Myrddin Rees, Tim G John, Sean Bygrave, Graham Plant
BMJ 2004;329:1045-1046, doi:10.1136/bmj.329.7473.1045-c
4. de Guzman E, Shankar MN, Mattox KL Limited volume resuscitation in
penetrating thoracoabdominal trauma.
AACN Clin Issues. 1999 Feb;10(1):61-8.
5. Should reducing the cardiac index be the therapeutic objective in
cardiogenic shock?
Richard G Fiddia-Green (19 August 2004)eLetter re: Noelle Lim, Marc-
Jacques Dubois, Daniel De Backer, and Jean-Louis Vincent
Do All Nonsurvivors of Cardiogenic Shock Die With a Low Cardiac Index?
Chest 2003; 124: 1885-1891
6. Richard G Fiddian-Green
Might these patients do better without inotropes?
http://www.heartjnl.com/cgi/eletters/82/2/248#402, 14 Aug 2004
7. Fiddian-Green RG. Monitoring of tissue pH: the critical
measurement.
Chest. 1999 Dec;116(6):1839-41.
8. Worshipping false gods
Richard G Fiddian-Green
Chest Online, 13 Sep 2003
A call to worship a new god, tissue pH.
Richard G Fiddian-Green (28 June 2004) eLetters re: David Roy Dantzker
Monitoring Tissue Oxygenation : The Quest Continues
Chest 2001; 120: 701-702
9. Chalfin DB, Holbein ME, Fein AM, Carlon GC. Cost-effectiveness of
monoclonal antibodies to gram-negative endotoxin in the treatment of gram-
negative sepsis in ICU patients.
JAMA. 1993 Jan 13;269(2):249-54.
Competing interests:
None declared
Competing interests: No competing interests
Re: Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care
As this article passes its 10th birthday, we have been gratified at the extent to which it has been quoted in the literature (approaching 500 citations according to Google Scholar) and even more so by the way in which its ideas - particularly our concept of clinical mindlines - have been entering into the discourse about the implementation of evidence-based practice across a range of health professions. However we would point out that this article represented a very early stage in our thinking about this topic, and was necessarily limited in its scope. Whilst we recognise that modern bibliographic search methods will always tend to take researchers to journal articles rather than books - and that articles are much quicker to read! - we hope that those who are interested in pursuing the topic will also consider delving into the kind of detail that books, rather than short articles such as this, can bring to one's understanding of such complex matters.
Our subsequent book on this topic (1), which was published 7 years after this paper and was based on considerable additional fieldwork within this ethnography and other supplementary ones that we designed to better elucidate the emerging findings, corroborates the results and conclusions set out in this article. But it takes them a great deal further. In particular, we explore much more deeply the significance of our findings for the promulgation and use of clinical guidelines ; the educational implications of the ways in which mindlines are developed and used over a clinician's career; the concept of what we call 'knowledge-in-practice-in-context' as opposed to the simple knowledge in practice discussed in the article; the suggestion of 'contextual adroitness' as a refinement of current theories of expertise; the role of storytelling and narrative in the growth and transmission of mindlines; and the role of communities of practice, 'actor networks' and other peer groupings in developing both individual and collective mindlines. We link these and other findings to a range of social, organisational, educational and philosophical theories that help shed light on their significance. We also consider in some detail the implications of our findings for clinical practice, for clinical education and for the conduct, dissemination and implementation of health research among policymakers, practitioners, managers and patients.
Although, 10 years on, this letter hardly counts as a ‘rapid response’, we felt it worthwhile to point out this further source in case readers who are interested in following up the ideas raised in this article were unaware of it.
1 Gabbay J le May A: (2011) Practice-based evidence for healthcare: Clinical mindlines. London: Routledge
Competing interests: We are the authors of this article and the book to which we refer here