Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care
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《英国医生杂志》
1 Wessex Institute for Health Research and Development, Community Clinical Sciences, University of Southampton, Southampton SO16 7PX, 2 School of Nursing and Midwifery, University of Southampton
Correspondence to: J Gabbay j.gabbay@soton.ac.uk
Abstract
Use of guidelines
We found that the individual practitioners did not go through the steps that are traditionally associated with the linear-rational model of evidence based health care1-3—not once in the whole time we were observing them. Neither while we observed them did they read the many clinical guidelines available to them in paper form or electronically, except to point to one of the laminated guidelines on the wall in order to explain something to a patient or to us. They told us that they would look through guidelines at their leisure, either in preparation for a practice meeting at which they were expected to bring the practice policy for a given clinical condition up to date or more informally to ensure that their own practice was generally up to standard. For example, one partner told us that when a new guideline arrived in the post he would leaf through it—as long as it looked authoritative and well produced—to reassure himself that there was nothing major that needed changing in his practice. If there was, he would discuss it with colleagues before deciding how to handle the discrepancy. The nurses told us that they would turn to guidelines when faced with an unfamiliar problem, and that once they were familiar with the procedure—for nurse triage of presenting patients, for example—they would rarely if ever look at the guideline again. Although the practice's sophisticated computer system allowed easy direct access to several accepted expert systems, and more generally to the internet, GPs very rarely used them. Their own average estimates were usually that they might use such facilities less than once every week; even then it would probably be only to download information to give to patients. Indeed, we never saw them use such systems to solve a clinical problem in real time.
Box 1: Summary of data sources from Lawndale
Observations and informal interviews
10 GP surgeries
6 sets of home visits by GPs
4 nurse led surgeries
1 interview and half day observation with practice manager
Practice meetings:
1 lunchtime executive meeting
3 routine partners' meetings
1 continuing professional development meeting
1 meeting of administrative staff
1 awayday of all practice staff
1 awayday of partners and practice manager
1 practice meeting on coronary heart disease audit
Multiple informal coffee room gatherings and one to one and informal group discussions
10 "quality practice award" meetings of practice staff (all the quality practice award meetings over one year, of which three were recorded and transcribed)
1 quality practice award nurse team meeting
1 meeting of GP representatives from all local practices to discuss primary care trust-wide coronary heart disease audit
7 "new GP contract" meetings of practice staff
1 "new GP contract" meeting of GPs only
Formal interviews
3 interviews with GPs
1 group interview with clinic staff (practice nurses and phlebotomist)
Documentary sources
Practice guidelines, manuals, and protocols
One partner's "fellowship by assessment" portfolio
"Quality practice award" submission drafts
Networks
Rather than directly accessing new knowledge in the literature or from the internet and other written sources, the practitioners nearly always took shortcuts to acquiring what they thought would be the best evidence base from sources that they trusted. These sources included the popular doctors' and nurses' magazines mailed free of charge to practices in the United Kingdom. Most importantly, however, the shortcut to the best up to date practice was—for the GPs—via their professional networks among other doctors. The nurses had far fewer opportunities for such external networking and relied more on localised links between themselves, the practice doctors, and the community nurses linked to the surgery.
Box 2: From data to interpretation: example of process of analysis
During a conversation about the way in which the partners learn from each other, a Lawndale GP had told JG that they tended to use "anecdotes with a purpose." This comment was noted on a Post-it sticker, together with the date and field book reference. We placed the sticker on the whiteboard among a growing cluster of around 30 similar notes in a section labelled "Meetings." Other items there included "I'm generally OK about it if a partner later disagrees with my diagnosis or my actions," which had been noted six months earlier in a chat about the extent to which GPs discussed their cases; another item, from five months earlier, noted that the senior partner had smilingly admitted that his "younger partners would gently point out" where his practice was not up to date. We felt that these data seemed to relate to another note about how the practice's policy on statins had developed from the practitioners' individual decisions, which they had shared through informal chats, eventually leading to a formal meeting in which one partner led an audit on use of statins; this, they said, had been followed by argument and discussion and someone agreeing to read up some detail and report back. So perhaps the relevant heading was not only "Meetings," we decided, but broader than that: so we added the label "Each other."
Near to this cluster was a note of an ironic joke—made in the coffee room when a local consultant was visiting—about how GPs "always keep up with the all research literature ." We recalled, on returning to the field notes, how avidly the partners capitalised on the consultant's visit to find out about the latest developments in his field and to ask him—both through the coffee room chat and at a lunchtime seminar—about some recent difficult cases. Was this not, we asked ourselves, an example of the importance of "Meetings," rather an "Each other?" Or was it "Education/CPD?" We also linked it to a nearby cluster called "Opinion leaders" and then realised that although many opinion leaders were external to the practice, some were internal, as in the example of statins policy development. This was amply confirmed when we later saw how partners took leading roles—for example, on asthma or diabetes—at formal practice meetings. It became clear as this train of analysis developed that once the group had entrusted themselves to the expertise of an external or internal opinion leader, they would not then question the evidence source. Moreover, they often vaguely referred to those same "meetings with each other" when we asked them to reflect on the reasons for decisions about individual patients. So was this indicative of collective mindline development?
Networking was vital in order to know which colleagues to trust. A great deal of the social interaction and professional comings and goings between doctors, nurses, and other practice staff (and beyond) could be seen as a way of checking out who or what were the most authoritative and trustworthy sources and ascertaining what "they say." However, our participants rarely if ever questioned whether "they" (that is, authoritative sources) practised the linear-rational process traditionally linked to evidence based health care (fig 1, levels 1 and 2), or even the extent to which the views that they conveyed were rooted in explicit research evidence (level 3). This was simply assumed on the basis of trust in "their" expertise. In contrast, the views relayed to practitioners by pharmaceutical representatives, and to a lesser extent the centre of the NHS, were regarded with considerable scepticism, although that did not necessarily mean that they were without influence, as the practitioners themselves admitted. The local primary care trust pharmaceutical adviser had, however, earned the respect of the practitioners and was a highly trusted source.
"Mindlines"
In short, we found that clinicians rarely accessed, appraised, and used explicit evidence directly from research or other formal sources; rare exceptions were where they might consult such sources after dealing with a case that had particularly challenged them. Instead, they relied on what we have called "mindlines," 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. The clinicians, in general, would refine their mindlines by acquiring tacit knowledge from trusted sources, mainly their colleagues, in ways that were mediated by the organisational features of the practice, such as the nature and frequency of meetings, the practice ethos, and its financial and structural features, including the computer system.
When describing what we call mindlines, clinicians told us, for example, that they were grown from experience and from people who are trusted; they were "stored in my head" but could be shared and tested and then internalised through discussion, while leaving room for individual flexibility. Once compiled, each individual practitioner's mindlines were adjusted by checking them out against what was learnt from brief reading or from discussions with colleagues, either within or outside the practice. The mindline might well be modified when applied to an individual patient after discussion and negotiation during the consultation; at this stage patients' ideas of what is the appropriate evidence about their particular case (their own personal history, what their family has experienced, what they have read in the media, and so on) could influence the application or even the continuing development of the mindline. Further adjustment might subsequently happen during swapping stories with colleagues or in audit or "critical incident meetings." In those rare challenging cases in which practitioners felt they did not have a ready mindline, they would later read up or ask around so that they could develop one for the future.
Mindlines were therefore iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid communities of practice, interactions with and experience of patients, and practice meetings. The result was day to day practice based on socially constituted knowledge (fig 2).
Fig 2 Construction of mindlines
We observed the same pattern of knowledge management in the "quality practice award" and other practice meetings. When formulating a practice protocol for the management of a given condition, clinicians relied on one of the partners with a special interest in that field to produce a summary of current best practice (box 3). These discussions sometimes resulted in modification of the computerised protocols that were available to prompt clinical actions, but which were not often actually needed as they had already been internalised through the discussions.
Conclusions and implications
Muir Gray J. Evidence-based healthcare: how to make health policy and management decisions. Edinburgh: Churchill Livingstone, 1998.
Haines A, Donald A, eds. Getting research into practice. London: BMJ Books, 1998.
Trinder L, Reynolds S, eds. Evidence-based practice: a critical appraisal. Oxford: Blackwell Science, 2000.
Davenport TK, Prusak L Working knowledge: how organisations manage what they know. Boston: Harvard Business School Press, 1998.
Polanyi M. Personal knowledge: towards a post-critical philosophy. London: Routledge and Kegan Paul, 1958.
Polanyi M. The tacit dimension. London: Routledge and Kegan Paul, 1967.
Nonaka I, Takeuchi H. The knowledge creating company: how Japanese companies create the dynamics of innovation. Oxford: Oxford University Press, 1995.
Lave J. The values of quantification. In: Law J, ed. Power, action and belief: a new sociology of knowledge? (Sociological Review Monograph 32.) London: Routledge and Kegan Paul, 1986.
Dopson S, Fitzgerald L, Ferlie E, Gabbay J, Locock L. No magic targets! Changing clinical practice to become more evidence based. Health Care Manage Rev 2002;27: 35-47.
Le May A, Mulhall A, Alexander C. Bridging the research practice gap: exploring the research cultures of practitioners and managers. J Adv Nurs 1998;28: 428-37.
Fitzgerald L, Ferlie E, Wood M, Hawkins C. Interlocking interactions, the diffusion of innovations in health care. Hum Relat 2002;55: 1429-49.
Ferlie E, Fitzgerald L, Wood M. Getting evidence into clinical practice: an organisational behaviour perspective. J Health Serv Res Policy 2000;5: 96-102.
Hamm RM. Medical decision scripts: combining cognitive scripts and judgement strategies to account fully for medical decision making. In: Hardman D, Macchi L, eds. Thinking: psychological perspectives on reasoning, judgement and decision making. London and New York: John Wiley and Sons, 2003: 315-45.
Andre M, Borgquist L, Foldevi M, Molstad S. Asking for `rules of thumb': a way to discover tacit knowledge in general practice. Fam Pract 2002;19: 617-22.
Andre M, Borgquist L, Molstad S. Use of rules of thumb in the consultation in general practice—an act of balance between the individual and the general perspective. Fam Pract 2003;20: 514-9.
Pope CJ. Resisting evidence: the study of evidence-based medicine as a contemporary social movement. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 2003;7: 267-82.
Eriksen TH. Small places, large issues: an introduction to social and cultural anthropology. London: Pluto Press, 2001.
Agar MH. The professional stranger. San Diego: Academic Press, 1996.
Spradley JP. The ethnographic interview. Florida: Harcourt Brace Jovanovich, 1979.
Weick K. Sensemaking in organizations. Thousand Oaks, CA: Sage Publications, 1995.
Wenger E. Communities of practice: learning, meaning and identity. New York: Cambridge University Press, 1998.
Brown JS, Duguid P. Organisational learning and communities of practice: towards a unified view of working, learning, and innovation. Organisational Science 1991;2: 40-57.
Gabbay J, le May A, Jefferson H, Webb D, Lovelock R, Powell J, et al. A case study of knowledge management in multi-agency consumer-informed "communities of practice": implications for evidence-based policy development in health and social services. Health: An interdisciplinary Journal for the Social Study of Health, Illness and Medicine 2003;7: 283-310.
Lincoln Y, Guba R. Naturalistic inquiry. Beverly Hills: Sage, 1985.
Choo CW. The knowing organization: how organizations use information to construct meaning, create knowledge and make decisions. New York and Oxford: Oxford University Press, 1998.
Brown JS, Duguid P. The social life of information. Boston: Harvard Business School Press, 2000.
Latour B. Science in action: how to follow scientists and engineers through society. Boston: Harvard University Press, 1988.
Callon M. Some elements of a sociology of translation: domestication of the scallops and the fishermen of St Brieuc Bay. In: Law J, ed. Power, action and belief: a new sociology of knowledge? (Sociological Review Monograph 32.) London: Routledge and Kegan Paul, 1986.
Coleman JS, Katz E, Menzel H. Medical innovation, a diffusion study. Indianapolis: Dobbs Merrill, 1966.
Locock L, Dopson S, Chambers D, Gabbay J. Understanding the role of opinion leaders in improving clinical effectiveness. Soc Sci Med 2001;53: 745-57.(John Gabbay, professor of)
Correspondence to: J Gabbay j.gabbay@soton.ac.uk
Abstract
Use of guidelines
We found that the individual practitioners did not go through the steps that are traditionally associated with the linear-rational model of evidence based health care1-3—not once in the whole time we were observing them. Neither while we observed them did they read the many clinical guidelines available to them in paper form or electronically, except to point to one of the laminated guidelines on the wall in order to explain something to a patient or to us. They told us that they would look through guidelines at their leisure, either in preparation for a practice meeting at which they were expected to bring the practice policy for a given clinical condition up to date or more informally to ensure that their own practice was generally up to standard. For example, one partner told us that when a new guideline arrived in the post he would leaf through it—as long as it looked authoritative and well produced—to reassure himself that there was nothing major that needed changing in his practice. If there was, he would discuss it with colleagues before deciding how to handle the discrepancy. The nurses told us that they would turn to guidelines when faced with an unfamiliar problem, and that once they were familiar with the procedure—for nurse triage of presenting patients, for example—they would rarely if ever look at the guideline again. Although the practice's sophisticated computer system allowed easy direct access to several accepted expert systems, and more generally to the internet, GPs very rarely used them. Their own average estimates were usually that they might use such facilities less than once every week; even then it would probably be only to download information to give to patients. Indeed, we never saw them use such systems to solve a clinical problem in real time.
Box 1: Summary of data sources from Lawndale
Observations and informal interviews
10 GP surgeries
6 sets of home visits by GPs
4 nurse led surgeries
1 interview and half day observation with practice manager
Practice meetings:
1 lunchtime executive meeting
3 routine partners' meetings
1 continuing professional development meeting
1 meeting of administrative staff
1 awayday of all practice staff
1 awayday of partners and practice manager
1 practice meeting on coronary heart disease audit
Multiple informal coffee room gatherings and one to one and informal group discussions
10 "quality practice award" meetings of practice staff (all the quality practice award meetings over one year, of which three were recorded and transcribed)
1 quality practice award nurse team meeting
1 meeting of GP representatives from all local practices to discuss primary care trust-wide coronary heart disease audit
7 "new GP contract" meetings of practice staff
1 "new GP contract" meeting of GPs only
Formal interviews
3 interviews with GPs
1 group interview with clinic staff (practice nurses and phlebotomist)
Documentary sources
Practice guidelines, manuals, and protocols
One partner's "fellowship by assessment" portfolio
"Quality practice award" submission drafts
Networks
Rather than directly accessing new knowledge in the literature or from the internet and other written sources, the practitioners nearly always took shortcuts to acquiring what they thought would be the best evidence base from sources that they trusted. These sources included the popular doctors' and nurses' magazines mailed free of charge to practices in the United Kingdom. Most importantly, however, the shortcut to the best up to date practice was—for the GPs—via their professional networks among other doctors. The nurses had far fewer opportunities for such external networking and relied more on localised links between themselves, the practice doctors, and the community nurses linked to the surgery.
Box 2: From data to interpretation: example of process of analysis
During a conversation about the way in which the partners learn from each other, a Lawndale GP had told JG that they tended to use "anecdotes with a purpose." This comment was noted on a Post-it sticker, together with the date and field book reference. We placed the sticker on the whiteboard among a growing cluster of around 30 similar notes in a section labelled "Meetings." Other items there included "I'm generally OK about it if a partner later disagrees with my diagnosis or my actions," which had been noted six months earlier in a chat about the extent to which GPs discussed their cases; another item, from five months earlier, noted that the senior partner had smilingly admitted that his "younger partners would gently point out" where his practice was not up to date. We felt that these data seemed to relate to another note about how the practice's policy on statins had developed from the practitioners' individual decisions, which they had shared through informal chats, eventually leading to a formal meeting in which one partner led an audit on use of statins; this, they said, had been followed by argument and discussion and someone agreeing to read up some detail and report back. So perhaps the relevant heading was not only "Meetings," we decided, but broader than that: so we added the label "Each other."
Near to this cluster was a note of an ironic joke—made in the coffee room when a local consultant was visiting—about how GPs "always keep up with the all research literature ." We recalled, on returning to the field notes, how avidly the partners capitalised on the consultant's visit to find out about the latest developments in his field and to ask him—both through the coffee room chat and at a lunchtime seminar—about some recent difficult cases. Was this not, we asked ourselves, an example of the importance of "Meetings," rather an "Each other?" Or was it "Education/CPD?" We also linked it to a nearby cluster called "Opinion leaders" and then realised that although many opinion leaders were external to the practice, some were internal, as in the example of statins policy development. This was amply confirmed when we later saw how partners took leading roles—for example, on asthma or diabetes—at formal practice meetings. It became clear as this train of analysis developed that once the group had entrusted themselves to the expertise of an external or internal opinion leader, they would not then question the evidence source. Moreover, they often vaguely referred to those same "meetings with each other" when we asked them to reflect on the reasons for decisions about individual patients. So was this indicative of collective mindline development?
Networking was vital in order to know which colleagues to trust. A great deal of the social interaction and professional comings and goings between doctors, nurses, and other practice staff (and beyond) could be seen as a way of checking out who or what were the most authoritative and trustworthy sources and ascertaining what "they say." However, our participants rarely if ever questioned whether "they" (that is, authoritative sources) practised the linear-rational process traditionally linked to evidence based health care (fig 1, levels 1 and 2), or even the extent to which the views that they conveyed were rooted in explicit research evidence (level 3). This was simply assumed on the basis of trust in "their" expertise. In contrast, the views relayed to practitioners by pharmaceutical representatives, and to a lesser extent the centre of the NHS, were regarded with considerable scepticism, although that did not necessarily mean that they were without influence, as the practitioners themselves admitted. The local primary care trust pharmaceutical adviser had, however, earned the respect of the practitioners and was a highly trusted source.
"Mindlines"
In short, we found that clinicians rarely accessed, appraised, and used explicit evidence directly from research or other formal sources; rare exceptions were where they might consult such sources after dealing with a case that had particularly challenged them. Instead, they relied on what we have called "mindlines," 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. The clinicians, in general, would refine their mindlines by acquiring tacit knowledge from trusted sources, mainly their colleagues, in ways that were mediated by the organisational features of the practice, such as the nature and frequency of meetings, the practice ethos, and its financial and structural features, including the computer system.
When describing what we call mindlines, clinicians told us, for example, that they were grown from experience and from people who are trusted; they were "stored in my head" but could be shared and tested and then internalised through discussion, while leaving room for individual flexibility. Once compiled, each individual practitioner's mindlines were adjusted by checking them out against what was learnt from brief reading or from discussions with colleagues, either within or outside the practice. The mindline might well be modified when applied to an individual patient after discussion and negotiation during the consultation; at this stage patients' ideas of what is the appropriate evidence about their particular case (their own personal history, what their family has experienced, what they have read in the media, and so on) could influence the application or even the continuing development of the mindline. Further adjustment might subsequently happen during swapping stories with colleagues or in audit or "critical incident meetings." In those rare challenging cases in which practitioners felt they did not have a ready mindline, they would later read up or ask around so that they could develop one for the future.
Mindlines were therefore iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid communities of practice, interactions with and experience of patients, and practice meetings. The result was day to day practice based on socially constituted knowledge (fig 2).
Fig 2 Construction of mindlines
We observed the same pattern of knowledge management in the "quality practice award" and other practice meetings. When formulating a practice protocol for the management of a given condition, clinicians relied on one of the partners with a special interest in that field to produce a summary of current best practice (box 3). These discussions sometimes resulted in modification of the computerised protocols that were available to prompt clinical actions, but which were not often actually needed as they had already been internalised through the discussions.
Conclusions and implications
Muir Gray J. Evidence-based healthcare: how to make health policy and management decisions. Edinburgh: Churchill Livingstone, 1998.
Haines A, Donald A, eds. Getting research into practice. London: BMJ Books, 1998.
Trinder L, Reynolds S, eds. Evidence-based practice: a critical appraisal. Oxford: Blackwell Science, 2000.
Davenport TK, Prusak L Working knowledge: how organisations manage what they know. Boston: Harvard Business School Press, 1998.
Polanyi M. Personal knowledge: towards a post-critical philosophy. London: Routledge and Kegan Paul, 1958.
Polanyi M. The tacit dimension. London: Routledge and Kegan Paul, 1967.
Nonaka I, Takeuchi H. The knowledge creating company: how Japanese companies create the dynamics of innovation. Oxford: Oxford University Press, 1995.
Lave J. The values of quantification. In: Law J, ed. Power, action and belief: a new sociology of knowledge? (Sociological Review Monograph 32.) London: Routledge and Kegan Paul, 1986.
Dopson S, Fitzgerald L, Ferlie E, Gabbay J, Locock L. No magic targets! Changing clinical practice to become more evidence based. Health Care Manage Rev 2002;27: 35-47.
Le May A, Mulhall A, Alexander C. Bridging the research practice gap: exploring the research cultures of practitioners and managers. J Adv Nurs 1998;28: 428-37.
Fitzgerald L, Ferlie E, Wood M, Hawkins C. Interlocking interactions, the diffusion of innovations in health care. Hum Relat 2002;55: 1429-49.
Ferlie E, Fitzgerald L, Wood M. Getting evidence into clinical practice: an organisational behaviour perspective. J Health Serv Res Policy 2000;5: 96-102.
Hamm RM. Medical decision scripts: combining cognitive scripts and judgement strategies to account fully for medical decision making. In: Hardman D, Macchi L, eds. Thinking: psychological perspectives on reasoning, judgement and decision making. London and New York: John Wiley and Sons, 2003: 315-45.
Andre M, Borgquist L, Foldevi M, Molstad S. Asking for `rules of thumb': a way to discover tacit knowledge in general practice. Fam Pract 2002;19: 617-22.
Andre M, Borgquist L, Molstad S. Use of rules of thumb in the consultation in general practice—an act of balance between the individual and the general perspective. Fam Pract 2003;20: 514-9.
Pope CJ. Resisting evidence: the study of evidence-based medicine as a contemporary social movement. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 2003;7: 267-82.
Eriksen TH. Small places, large issues: an introduction to social and cultural anthropology. London: Pluto Press, 2001.
Agar MH. The professional stranger. San Diego: Academic Press, 1996.
Spradley JP. The ethnographic interview. Florida: Harcourt Brace Jovanovich, 1979.
Weick K. Sensemaking in organizations. Thousand Oaks, CA: Sage Publications, 1995.
Wenger E. Communities of practice: learning, meaning and identity. New York: Cambridge University Press, 1998.
Brown JS, Duguid P. Organisational learning and communities of practice: towards a unified view of working, learning, and innovation. Organisational Science 1991;2: 40-57.
Gabbay J, le May A, Jefferson H, Webb D, Lovelock R, Powell J, et al. A case study of knowledge management in multi-agency consumer-informed "communities of practice": implications for evidence-based policy development in health and social services. Health: An interdisciplinary Journal for the Social Study of Health, Illness and Medicine 2003;7: 283-310.
Lincoln Y, Guba R. Naturalistic inquiry. Beverly Hills: Sage, 1985.
Choo CW. The knowing organization: how organizations use information to construct meaning, create knowledge and make decisions. New York and Oxford: Oxford University Press, 1998.
Brown JS, Duguid P. The social life of information. Boston: Harvard Business School Press, 2000.
Latour B. Science in action: how to follow scientists and engineers through society. Boston: Harvard University Press, 1988.
Callon M. Some elements of a sociology of translation: domestication of the scallops and the fishermen of St Brieuc Bay. In: Law J, ed. Power, action and belief: a new sociology of knowledge? (Sociological Review Monograph 32.) London: Routledge and Kegan Paul, 1986.
Coleman JS, Katz E, Menzel H. Medical innovation, a diffusion study. Indianapolis: Dobbs Merrill, 1966.
Locock L, Dopson S, Chambers D, Gabbay J. Understanding the role of opinion leaders in improving clinical effectiveness. Soc Sci Med 2001;53: 745-57.(John Gabbay, professor of)