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What is 'valid' knowledge?

Mindlines, philosophy and virtual networks beyond EBM

Sietse Wieringa

on 24 October 2015

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Transcript of What is 'valid' knowledge?

What is 'valid' knowledge?
10 years of mindlines: a systematic review and commentary
The quest
How to

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, philosophy and virtual networks 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
a moral duty in healthcare?
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 Healthcare Management MSc
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?
‘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
‘succinct sayings that offer advice should function as ‘interface between intuitive approaches to make rapid decisions, and the implementation of specialty-specific clinical guidelines’
Virtual networks
The sociocultural context of the development of knowledge and ‘facts’ in science
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?
What is 'valid'?
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.
deficit model - a moral problem
group versus single case scenario
Ian Hacking
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
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)
Protocol and guideline creation
- a 'black box' activity?
Bruno Latour
Steven Woolgar
"EBM requires a bottom up approach that
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
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’
Open access http://t.co/Fh33wemKy1
Philosophical assumptions of EBM challenged
in mindlines concept
for references
please check original paper
Full transcript