Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

‘Hard and ‘soft’ knowledge

Guidelines and Mindlines in Medical Knowledge Creation:
by

Sietse Wieringa

on 24 February 2017

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of ‘Hard and ‘soft’ knowledge

'Hard' and 'soft'
Knowledge

10 years of mindlines: a systematic review and commentary
The quest
How to
ASAP
everything
know

Term ‘mindline(s)’

Tracking all sources that had cited Gabbay and le May’s 2004 article

PubMed, Web of Science, OvidSP, Embase or HMIC.

All sources except those where Mindline was an author’s name.
340 papers
Reality—single or multiple?
The nature
of knowledge
How the ‘truth’ is arrived at
Economics, politics
and ethics

Knowledge management, knowledge intermediation
Mindlines, guidelines and philosophy in medical knowledge creation beyond EBM
Implementation Science 2015, 10:45 doi:10.1186/s13012-015-0229-x
Sietse Wieringa and Trisha Greenhalgh
Is it time to drop the ‘knowledge translation’ metaphor? A critical literature review
Trisha Greenhalgh and Sietse Wieringa
J R Soc Med 2011: 104: 501–509. DOI 10.1258/jrsm.2011.110285
Evidence based medicine: a movement in crisis?
BMJ 2014;348:g3725 doi: 10.1136/bmj.g3725 (Published 13 June 2014)
Trisha Greenhalgh and colleagues argue that, although evidence based medicine has had many benefits, it has also had some negative unintended consequences. They offer a preliminary agenda for the movement’s renaissance, refocusing on providing useable evidence that can be combined with context and professional expertise so that individual patients get optimal treatment
Trisha Greenhalgh, Jeremy Howick, Neal Maskrey, for the Evidence Based Medicine Renaissance Group
Sietse Wieringa
GP UK & NL
Scientia Fellow / DPhil EBHC
NICE Clinical guideline update committee
GIN AID Working group member


Health & Society (HELSAM) Oslo University
CPD / Nuffield Primary Care Health Sciences Oxford University

Research should move beyond a narrow focus on the ‘know–do gap’ to cover a richer agenda, including: (a) the situation-
specific practical wisdom
(phronesis) that underpins clinical judgement; (b) the
tacit knowledge
that is built and shared among practitioners (‘mindlines’); (c) the complex
links between power and knowledg
e; and (d) approaches to
facilitating macro-level knowledge partnerships
between researchers, practitioners, policymakers and commercial interests.
BMJ volume 329 30 oct 2004 p1013
Ethnographic research by Gabbay and Le May found that clinicians rarely used explicit evidence from research and other sources directly in practice.




Mindlines can be thought of as a combination of explicit and tacit knowledge which are shared among social groups and which reinforce norms of good practice but which are also fluid, dynamic, constantly evolving.
Instead they drew heavily on socially shared knowledge and patterns of behaviour called ‘Mindlines’
Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care
John Gabbay, Andrée le May
Crisis in evidence based medicine?
• The evidence based “quality mark” has been misappropriated by vested interests
• The volume of evidence, especially clinical guidelines, has become unmanageable
• Statistically significant benefits may be marginal in clinical practice
• Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred
• Evidence based guidelines often map poorly to complex multimorbidity
How and to what extent has the concept of mindlines influenced EBM?
Methods
Results
‘There’s a tendency to criticize evidence in order to maintain the status quo, […] medical practice is currently dictated by traditional approaches and “collective mindlines”.’ [14].
‘solution focused’ view
‘theoretical and philosophical’ view
‘in-practice’ view
‘nominal’ view
‘Rather than following national guidelines for the diagnosis of febrile illness, clinician behaviour appeared to follow “mindlines”: shared rationales constructed from these different spheres of influence. Three mindlines were identified in this setting: malaria is easier to diagnose than alternative diseases; malaria is a more acceptable diagnosis; and missing malaria is indefensible. These mindlines were apparent during the training stages as well as throughout clinical careers.’ [21]
studying how mindlines emerge and spread in real-world settings
mindlines mentioned by name but not defined or explored
using mindlines to extend theory of knowledge sharing
proposals for how the development of evidence-based mindlines might be promoted and supported
Philosophy
‘succinct sayings that offer advice should function as ‘interface between intuitive approaches to make rapid decisions, and the implementation of specialty-specific clinical guidelines’
the concept of mindlines presents us with the idea of a shared (but by no means homogeneous) reality consisting of multiple very individual and temporary realities of people: clinicians, researchers, guideline makers and patients.
The mindlines concept envisions a ‘negotiating space’ [12] where clinical decision-making by clinicians and patients involves a process of reduction and prioritisation from a vast realm of potentially relevant knowledge of different kinds.
Reducing in the spirit of mindlines is a creative process, not a reductionist one, like carving a particular ‘abdominal pain’ out of a piece of buzzing, blooming reality [64] with an infinite number of dimensions.
Mindlines convey strong and rich elements of shared sense-making (and hence consensus-making), both conscious and unconscious; they address correspondence with reality as it pushes back in the local context; and they address coherence using other types of evasions of the induction problem. In sum, mindlines can be accurate and useful in a local setting and provide useful predictions, despite not being construed according the set of reduction tools and beliefs underpinning the EBM paradigm.
Frequency type reasoning is intended to make a fair inference at a group level. Mindlines lack an overarching ‘built-in’ criterion of what is right or wrong patient care. With other authors, Gabbay and le May worry that mindlines can spread ‘collective folly’ [12].


EBM assumes that knowledge can be managed, and that, through intermediation, the knowledge deficit of both practitioners and patients can be rectified. But mindlines are about tacit knowlegde.
‘…the quest for context-independent evidence on the efficacy of knowledge exchange strategies is probably doomed’
Broekaert noticed ‘real human commitment consists of an open, methodical, meaningful search for the best solution for a certain problem’ [83].
Applied to mindlines, this may translate to a call to create a broad menu of mindlines to find where collective reality ‘resists’ using many methods of truth finding.
If we want to intermediate the process of knowledge creation (to the limited extent that this is possible), further research needs to look into how to speed up the cycle of building and turning over many more persistent mindlines, whilst keeping alternative, less persistent ones afloat efficiently.
In contrast, mindlines allow other evasions of the induction problem (such as Bayesian learning from a one-off experience) [67] in a chain of reasoning that might be termed reality-to-pattern-to-reality, which allows practitioners to keep the network of causality intact from one case to the next.
a little bit..
Mindlines offer a view that the number of guidelines on any topic will never cease to expand because we expect new individual realities and scientific paradigms to emerge continuously.
9 april 2015
In 2004, Gabbay and le May confronted evidence-based medicine (EBM) by showing that most of the time, clinicians base their decisions and actions on mindlines—internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines.
RCT: Frequency type reasoning
Problem of induction
Evasion 1
Bayesian reasoning
Evasion 2
Evasion x?
Correspondence
Consensus
Coherence
What is 'valid'?
or?
EBM strongly adheres to the ‘deficit model’ [78], which entails that clinicians and patients are regarded as deficient in certain knowledge: evidence-based knowledge. This is considered a moral problem of ‘leaving people incapable of understanding the world around them’ [79]. Mindlines, on the other hand, correspond more with the idea that anyone, including patients, create valid knowledge too and can be ‘experts’ in consultations [80]. With the current evolution towards person-based medicine and practices [81], the deficit model may be set to give way to a more pluralist and constructivist one. But at the same time, this may uncomfortably question our basic assumptions about who decides what is good or bad care.
Bakhtin
deficit model - a moral problem
group versus single case scenario
Ian Hacking
Mindlines
who decides what is good or bad?
Is controlling knowledge creation actually feasible?
Directionless? - Persistence
As Contandriopoulos et al. conclude in their review on the dissemination of knowledge
Hasok Chang [88] argues that scientific realism should commit to pursue many theories to find where reality ‘resists’, whilst investing to preserve theories that did not seem to work that well. In the future, those might turn out to give helpful alternative insights.
Realism as -ism: a call to find where reality resists
Cycle of Creation and Turnover of Mindlines
Thomas Kuhn
Hasok Chang
Tsoukas
Mach
EBM Tools
EBM has introduced some tools to create valid knowledge

The concept of mindlines may help to extend the toolset
‘we know more than we can tell’
Polanyi
Open access http://t.co/Fh33wemKy1
http://t.co/Fh33wemKy1
Philosophical assumptions of EBM challenged
in mindlines concept
for references
please check original paper
A Sore Throat
22 year old female, 2 day history of sore throat. PMH-
OE feverish, T39.5; symmetrical enlarged red tonsils

41 year old male, 7 days history of sore throat, PMH tonsillectomy
OE well, T36.7, throat: bilateral wounds back of throat
What to do?
Zuiderent-Jerak T, Forland F, Macbeth F. BMJ [Internet]. 2012 Jan [cited 2015 Jan 26];345(October):e6702. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23043093
Guidelines should reflect all knowledge, not just clinical trials.
knowledge from other types of evidence, for instance outbreak investigations, laboratory research, mathematical modelling, qualitative research, or quality improvement processes and clinical audit are under-used and under-represented in clinical guidance
1. Dominance of RCTs in guideline development
Guidelines International Network AID working group
2. There are other ways of reasoning we already use to make good inferences in clinical guidelines, and increasingly in other areas of guideline development
GIN is currently trying to identify “methods and promising initiatives for appraising and including a wider range of knowledge sources in guidelines”
(which members include staff from NICE, NHG and other influential guideline developing institutions)
3. Reasoning in guideline development is under-articulated and we need methods to do it better.
How to expand the toolset?
A collaboration
> home, watching TV
> hospitalised with blood cancer
1. What is knowledge?
33 year old female, 3 days history of sore throat,
OE well, T37.6, throat: bulging swelling left side
> in theatre for operation
30 year old male, 7 days history of sore throat,
OE well, T36.7, throat: nad
> drinking beer with friends, taking antibiotics
Knowledge in practice in context
Broader than pattern recognition , includes skills, norms, attitudes, infrastructural constraints
Continuously updated and merged
Many varied sources
Stories and anecdotes are instrumental
Communities of practice
Both individual and collective
Co-construction of clinical reality
4. How to find and study mindlines?
AnneMarie Mol
Logic of care
Wenger: "Communities of practice are groups of people who share a concern or a
passion for something they do and learn how to do it better as they
interact regularly." Domain - Community - Practice
Clifford Geertz
'Common sense
' messy and internally inconsistent, yet natural and straightforward
Pierre Bordieu
'Habitus'
the collective and practiced embodiment of the group's norms
Athony Giddens
'Structuration'
Every action has components of social forces beyond control and personal behaviours within control
Social constructivist perspective (Kuhn, Lakatos, Barnes, Bloor etc).

Far from medical knowledge about asthma having consisted of proven, timeless, objective facts, it has appeared under scrutiny to be composed of limited interpretations of the complex phenomena of illness. The nature of those interpretations is formed by the world, a social world, in which the physician and patient happen to live; it also contributes to the formation of that world (Gabbay 1982:43).
Hurwitz, Greenhalgh, Launer, Charon etc. Narrative medicine as a approach that values stories as a way of making sense of complex events and understand them in their context.
Organisational knowledge conversion cycle and some examples. (source: Nonaka, I. and Takeuchi, H. (1995) The Knowledge-Creating Company: How Japanese Companies Create the Dynamics of Innovation. Oxford Univ. Press)
SECI model
?
What is valid knowledge?
Seminar
Knowledge Creation
A meta-narrative review - Kuhnian traditions
A Sore Throat
22 year old female, 2 day history of sore throat. PMH-
OE feverish, T39.5; symmetrical enlarged red tonsils

4 year old. mum worried about scarlet fever. on antibiotics.
OE well. throat nad.
What happens
home, watching TV
at home playing, stopped antibiotics
33 year old female, 3 days history of sore throat,
OE well, T37.6, throat: bulging swelling left side
in theatre for operation
42 year old. 10 days sore throat and rash. children scarlet fever?
OE well. T37.4. pink rash. throat & tongue nad.
eating out with friends, taking antibiotics
.....X
Everything Goes
NOT
How to
ASAP
everything
know
EBM
Knowledge

& Actions
The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
(Sacket 1996)
Yet, the foundation for integrating the available sources of knowledge remains unclear. (Malterud 2006)
'Integration'
What does it mean?
Vóórkomen van niet-purulente complicaties: penicilline reduceert de kans op acuut reuma met 73% ten opzichte van placebo (RR 0,27; 95%-BI 0,12 tot 0,60). Acute glomerulonefritis kwam niet voor in de behandelgroep (n = 2927) en in 2 gevallen in de controlegroep (n = 2220) (RR 0,22; 95%-BI 0,02 tot 2,08). Het zeer brede 95%-betrouwbaarheidsinterval omvat de ‘1’, zodat het onduidelijk is of antibiotica bij keelpijn de kans op acute glomerulonefritis verminderen. NHG Standaard Acute Keelpijn Noot 13.
CKS Scarlet fever
Cochrane-review waarderen de mate van bewijskracht als hoog voor de uitkomstmaten keelpijn na 3 en na 7 dagen, vóórkomen van acuut reuma, abces en otitis media en als laag voor het vóórkomen van glomerulonefritis. Echter, de schatting van het effect van antibiotica op het vóórkomen van acuut reuma is onnauwkeurig omdat de absolute aantallen erg laag zijn (37 gevallen in de antibioticagroep (n = 5656) en 74 gevallen in de controlegroep (n = 5656)) en niet generaliseerbaar omdat (bijna) alle gevallen van acuut reuma vóórkomen in de RCT’s van voor 1960. Vandaar dat de werkgroep de bewijskracht voor deze uitkomstmaat verlaagt naar ‘laag’. Dit geldt ook voor de schatting van het effect van antibiotica op het vóórkomen van een abces.
worried
clinically suspected?
consensus
prevention complications
NHG Sore throat
Cochrane
PHE
Scarlet fever is a notifiable infectious disease caused by toxin-producing strains of the group A streptococcus bacterium (Streptococcus pyogenes).
7 minutes consultation
complaint?
Bij een standaardkeelkweek wordt alleen op GAS gekweekt en worden anaeroben niet gedetecteerd. Daarnaast bestaat er bij ongeveer 6 tot 30% van de kinderen en bij 1 tot 7% van de volwassenen streptokokkendragerschap waarbij geen relatie bestaat tussen de aanwezigheid van streptokokken en keelklachten. Verder is ongeveer 10% van de keelkweken fout-negatief en is de relatie tussen de uitslag van een keelkweek en bacteriën die dieper in de crypten voorkomen onduidelijk.
care
English, educated
ARF
<1960
Antibiotics, swabs, notify
peers
no swabs, no ABs, not notifiable
The foundations of evidence-based medicine
Sietse Wieringa

GP UK & NL

Research Fellow Health & Society (HELSAM) Oslo University
EBHC Oxford University

NICE
GIN

Knowledge Creation and EBM - About the seminar
carrier
What lies beyond
A series of seminars
Criticisms as directions for a future concept of EBM
About inference in real time
About validity as what stands out
About reality as an -ism
A broad definition of knowledge - mindlines
About knowledge creation
12.15
Advances in EBM
and trustworthy guidelines: Not such a crisis after all? Associate Professor Per Olav Vandvik

12.45
Appraising and including different knowledge
in guideline Development Project Leader Frode Forland & Research Fellow Teun Zuiderent-Jerak

13.15 Overnumerousness - Two views on
causation
Researcher Rani Lill Anjum

13.45 Tea break

14.00
Co-creating
knowledge between researchers and clinicians
Professor Nina K. Vøllestad

14.30
Diagnostic knowledge production
– and the “rationality” of its production machine. Professor Bjørn Hofmann

15.00 The
powers of objectivity
– power, interests and the production of evidence Professors Kristin Heggen & Eivind Engebretsen

15.30 Plenary discussion

16.00 Closing
Programme
How things appear to work
Type of reasoning (with examples of key scholars)
Evidence Based
Medicine
Induction In
Medicine
“Guidelines should reflect all knowledge, not just clinical trials”
AID Working group, Guideline International Network
Evidence based guidelines are typically based on RCTs, but they are less good at capturing other sources of evidence (Zuiderent, BMJ 2011)
This was not intended by the pioneers of EBM. Clinical expertise and patient preferences should be integrated with the best evidence (Sackett, BMJ 1996)
Instead they use ‘
mindlines
’: collectively shared, mostly tacit knowledge that is shaped by many sources including accumulated personal experiences, education (formal and informal), guidance and the narratives about patients that are shared among colleagues.
Clinicians in everyday practice situations do not explicitly or consciously use guidelines (Gabbay & Le May, BMJ 2004).
Everything Goes
NOT
How to
ASAP
everything
know
EBM
BMJ volume 329 30 oct 2004 p1013
Ethnographic research by Gabbay and Le May found that clinicians rarely used explicit evidence from research and other sources directly in practice.




Mindlines can be thought of as a combination of explicit and tacit knowledge which are shared among social groups and which reinforce norms of good practice but which are also fluid, dynamic, constantly evolving.
Instead they drew heavily on socially shared knowledge and patterns of behaviour called ‘Mindlines’
Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care
John Gabbay, Andrée le May
In 2004, Gabbay and le May confronted evidence-based medicine (EBM) by showing that most of the time, clinicians base their decisions and actions on mindlines—internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines.
Knowledge in practice in context
Broader than pattern recognition , includes skills, norms, attitudes, infrastructural constraints
Stories and anecdotes are instrumental
Communities of practice
Wenger: "Communities of practice are groups of people who share a concern or a
passion for something they do and learn how to do it better as they
interact regularly." Domain - Community - Practice
Hurwitz, Greenhalgh, Launer, Charon etc. Narrative medicine as a approach that values stories as a way of making sense of complex events and understand them in their context.
Bayesian evasion (Bayes, Hacking)
Abduction (Peirce)
Mechanistic reasoning
Anti-induction evasion (Popper)
Precautionary principle
Means-to-ends reasoning
Logic of Care (Mol)
Non-analytical reasoning (Gigerenzer, Stolper)
Frequency evasion (Hacking)
Shorthand Description
Learning from experience
Reasoning to the best explanation
Using intuition
Taking care while the uncertain future unfolds itself
Find ways to reach a goal
In case of uncertainty about the future prevent harm
Trial and error
A Sore Throat
22 year old female, 2 day history of sore throat. PMH-
OE feverish, T39.5; symmetrical enlarged red tonsils

4 year old. mum worried about scarlet fever. on antibiotics.
OE well. throat nad.
What happens
home, watching TV
at home playing, stopped antibiotics
33 year old female, 3 days history of sore throat,
OE well, T37.6, throat: bulging swelling left side
in theatre for operation
42 year old. 10 days sore throat and rash. children scarlet fever?
OE well. T37.4. pink rash. throat & tongue nad.
eating out with friends, taking antibiotics
.....X
Knowledge

& Actions
The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
(Sacket 1996)
Yet, the foundation for integrating the available sources of knowledge remains unclear. (Malterud 2006)
'Integration'
What does it mean?
Bij een standaardkeelkweek wordt alleen op GAS gekweekt en worden anaeroben niet gedetecteerd. Daarnaast bestaat er bij ongeveer 6 tot 30% van de kinderen en bij 1 tot 7% van de volwassenen streptokokkendragerschap waarbij geen relatie bestaat tussen de aanwezigheid van streptokokken en keelklachten. Verder is ongeveer 10% van de keelkweken fout-negatief en is de relatie tussen de uitslag van een keelkweek en bacteriën die dieper in de crypten voorkomen onduidelijk.
behavior of a chance setup
The overall intent is to enhance the implementability of guidelines by making them more relevant to the realities of patient care
3. So... How to:

(1) guide the content / format of guidelines
(2) improve the approaches employed to implement guidelines?
• Approach towards subjective knowledge & fear of bias
Acknowledge the need to work with, not against mindlines.
Rather than trying to eliminate the natural ways that people process knowledge when making complex decisions, guideline developers might achieve greater with respect to guideline implementation and use by working with, rather than against the grain.
• It is counterproductive to expect that guidelines will be precisely implemented
Instead, they are transformed in real-time based on an interacting variety of contextual issues
• Tacit knowledge is everywhere and here to stay.
Judith Hughes at St. Andrews is observing guideline development groups and is finding that tacit knowledge is considered and included in guidelines (though not explicitly).Thus guideline developers may already be drawing on a variety of sources of knowledge that do not necessarily reflect conventional evidence hierarchies
They noted that guideline developers who are clinicians understand the concept of mindlines and would not be resistant to it, but many guideline developers or those who coordinate guideline development are not clinicians, therefore not familiar with the complexity of clinical practice, and may reject the mindlines concept in favour of a more rationalistic approach that rules out “subjective” knowledge and accepts only strong empirical evidence
Mindlines at GIN
1. The purpose of guideline making
2. The problem of inductive inference and the dominance of frequentist reasoning

3. The problem of integration

Support clinical decision making
Ensure fair resource allocation
Improve patient experience
Facilitate efficient services

To infer
Virtual networks
The sociocultural context of the development of knowledge and ‘facts’ in science
Ethnographical research of the problems behind clinical trial protocol writing at an American cancer research group (Gennari et al. 2004)
How authors of guidance in Dutch insurance medicine redefined the meaning of objectivity (Timmermans and Berg 2003:132)
The contests between developers about what counts as knowledge in a protocol for a British telemedicine clinic (May and Ellis 2001)
Bruno Latour
Steven Woolgar
"EBM requires a bottom up approach that
integrates
the best external evidence with individual clinical expertise and patients' choice"
EBM What it is and what it isn't
BMJ 1996; 312 doi: http://dx.doi.org/10.1136/bmj.312.7023.71 (Published 13 January 1996)
David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W Scott Richardson
Protocol and guideline creation
- a 'black box' activity?
NICE - LETR
Forms of knowledge
Full transcript