What doctors really do (and why guidelines are only part of the answer)…

Gabbay J, le May A (2004).  Evidence based guidelines or collectively constructed `mindlines’?  Ethnographic study of knowledge management in primary care.  British Medical Journal; 329: 1013-1016.http://www.bmj.com/content/329/7473/1013

Why read this?

This is a powerful piece of research, based on more than five years close observation of a high-performing general practice.  This kind of ethnography is often used to great effect, from the jungles of Borneo to the street life of Chicago, to describe culture and practice in different groups.  The authors wanted to find out how clinicians actually use knowledge and where they look to for information and advice on everyday problems.   They immersed themselves in the daily life of the practice, from patient consultations to range of practice meetings with different staff, and checked out their emerging findings on how knowledge is formed with short visits to other practices and settings.

This study from two experienced researchers (both with clinical backgrounds – one medical, one nursing) shows the benefits of careful, embedded research over a period of years, reaching the parts that surveys and interviews alone cannot reach.   These are the realities of a busy Monday morning surgery when the partner is off sick and the locum hasn’t arrived, as opposed to scenario decision-making in the abstract.   As well as fascinating anecdote and case study, this piece of work benefits from wider knowledge of social science theory, from the new discipline of implementation science (pioneered in this country by Martin Eccles and others) to older work on professional knowledge and decision making. This short and powerful article (expanded in a readable book) provides a new way of thinking about evidence-based practice.   Rather than berate clinicians for not `following the book’, it provides illuminating insights into how people really make decisions and what influences practice.

  

What does this study say?

Looking at typical issues, from prescribing statins to screening for early kidney failure, the authors found that clinicians don’t make direct use of guidelines or formal research when they are practising.  But nor do they ignore them – instead, they follow `clinical mindlines’, which is made up of experience (both their own and colleagues in the practice) and a mix of formal and informal evidence.   This includes `tacit knowledge’ – patterns of thinking which may be deeply embedded and almost instinctive.   Several examples are given of these implicit clinical reasoning, such as the decision to admit a woman complaining of feeling `ice in her chest’.  But rather than opposing views of knowledge being codified (textbooks and guidelines) or tacit (intuition based on experience and decision rules), the authors argue that clinicians draw on both in a clinical mindline.  They highlight the importance of loose professional networks within and outside the practice to create and reinforce knowledge.  These informal links were important go give clinical knowledge the `social life’ which would ensure it was used – from coffee room chat with partners in the practice to wider diabetes networks.   Similarly, research showed the importance of stories and anecdotes in embedding knowledge in practice – including the power of real life `near-miss’ stories of patient harm.  In a successful practice, they also observed a collective clinical mindline, where they developed `ways of doing things’ by challenging and making sense of formal evidence, discussing anomalies from experience and refining and updating their knowledge of diseases and how to manage them.

We already knew from Trevor Sheldon and others http://tinyurl.com/8yjacnl more than ten years ago of the limited uptake of NICE guidelines, particularly where messages are complex …  Jeremy Grimshaw http://tinyurl.com/cv4eekv has shown in careful examination of evidence from controlled trials the limited effect of passive diffusion of guidelines.  

What does this mean for managers, who may not engage with clinical decision-making directly?   It throws light on the messy world of how knowledge is used – in fact, as pointed out in another classic research paper (Walshe and Rundall http://tinyurl.com/c63au2v), even more tricky for managers with a dispersed, loosely defined body of social science literature than clinicians where at least the formal knowledge is more organised, with defined hierarchy of evidence and mechanism for extracting recommendations (via NICE).  In making complex decisions like whether to decommission inpatient eating disorder services, managers are much more likely to be influenced by what other trusts have done, advice from experts near to hand, experience with similar specialist services locally and other forms of tacit knowledge than to consult a Cochrane review.   Managers, like doctors, are influenced by `worst last case’ – particularly if it risks ending up on the front page of the local newspaper.

Bite-size take-home message for managers (with apologies to the authors)

Who you know IS what you know.