Monday, May 18, 2009

Don't look up, and time passes swiftly by

Pay attention elsewhere, quite intensely, and minutes (hours, days, weeks) tiptoe fleetly past, leaving small tracks on your calendar. What was I gazing at? - I think I've been lost in words and thought, trying to achieve a cohesive sense of the terrain of my research. As I deepen my understanding, the landscape appears to shift, to develop fissures; rivulets wind away in new directions, and even the ground of my belief shifts. But so much of it is information that's not new to me - the difference is that I appear to be gaining a different perspective.

Paul Starr writes engagingly (and winningly, having garnered both a Pulitzer and Bancroft prize for his work) about the Social Transformation of American Medicine, tracing our path from an early reliance upon the individual, to authority vested in the physician and institutions. While I'd been aware of this history, and the struggle for power, it is instructive to consider it through the lens of evidence-based practice.

Think for a moment about this question: Could evidence-based practice in medicine be another permutation of the long struggle between different societal entities (private citizens, individual physicians, groups, etc.) for viability?

The tendency, unsurprisingly, has been to reinforce authority. Early on, the private citizen was responsible for their well being. While there were health practitioners prior to the 1910 Flexner Report, their authority was far from certain. Whether due to a lack of even marginally standardized education, networking, and a lack of technology, medics did not then hold the status and wealth they've had in more recent decades, and nor did their professional organizations wield such tremendous power.

But that authority is not absolute even today: Witness reports about the use of CAMs (and think how long it took to begin research on their efficacy), or the reaction, a decade back, of some physicians to patient-provided printouts; consider the dissatisfaction of many doctors in increasingly curtailed practice, and public discourses about trust (such as all those alarmist media reports entitled 10 Things your doctor may not ask you (and how it could shorten your life!)). I mean to say that physicians do not have absolute control over their professional destinies, and are subject to external pressures. Some might even say they are embattled.

Now, with this, and perhaps longer lasting, we have epistemological* tug-of-war: what is truth, illness, wellness? Who has the power to define these things? And beyond these questions:
  • What are the implications of this - and does an understanding of this issue enhance our view of EBM?
  • What elements of these issues might also be found in EBL?
I have been paying some attention to the first question, with several synapses occasionally linking to the second. Looking at EBM in any depth, it's impossible to prevent myself from also considering how the model has been adopted for LIS, and for other professions. In each, there's been struggle. I consider whether my understanding has been reductive, to the extent that I characterized opponents as wrong-headed, ill-informed. Following one of those rivulets of thought, I found a keynote address entitled 'The Politics of Evidence' published in the journal Qualitative Health Research (16:3, 2006, 395-), and began to consider the issues differently than I had. The author, Janice Morse, refers to Archie Cochrane, who identified randomized controlled trials as the pinnacle of research quality, and 'mere opinion' as of no value whatsoever. Morse claims that Cochrane had intended this classification for use with pharmacological trials only, but that EBM pioneers adopted the idea, stretching it far beyond the intended application. Sackett's 1993 standards for quality of evidence** give a grade of C to levels 3, 4, and 5 in research, which are called unsuitable for use as evidence:
  • Level III: non-randomized to group concurrent cohort comparison
  • level IV: no comparison group
  • level V: opinions of expert committees.
By this ranking, claims Morse, qualitative research is classified as grade C, and effectively ignored until very recently:
"But my major concern is that disciplines that were the primary users of qualitative inquiry with a mandate for health work virtually excluded from the resources provided for medical research. That is, research from disciplines such as nursing, rehabilitation, occupational therapy, counseling social work, and the humanistic specialties in medicine, such as family practice and psychiatry, became less credible" (Morse, 397).
I think it may have been this paragraph that affected me most deeply, perhaps because (as I'd said before) I am constantly thinking about contrast between EBM and EBL. I am still thinking about it. If we borrow the structure for EBL from EBM, what legacy of thought might we also be acquiring? I have seen no discussion of epistemological concerns for LIS in the implementation of evidence-based practice, but I have seen literature in healthcare sociology journals about variant sources of knowledge - including tacit. Rather than identifying 'tacit' simplistically as the known, I like Polanyi's distinction between tacit knowledge as knowing how ('embodied') and explicit knowledge as knowing what ('embrained').*** (sorry about all these stars!) To quote Morse, "Tacit knowledge is intuitive, acquired through practical experience and as such, is personal and contextual and cannot be readily made explicit or formalised" (184).

To extend this discussion, I'd like to remind the reader (or myself, at least) that concerns about the use of research in LIS and elsewhere have often centered around individual practitioners' lack of use of published, quality information, preferring to consult with peers. I say this with no lessened awareness of the problems of bias and currency inherent with 'expert advice.'

I had earlier read Gabbay and le May (2004****) on 'guidelines or collectively constructed "mindlines,"' and honestly did not think much of that study, which appeared to me to fall into the opposing camp of 'EBM as thief of autonomy.' In this work the authors found that clinicians seldom consult the medical literature relying instead on local channels of information. in my own mind, I had classified the study among a small group I'd use to depict a sort of 'state-of-the-art' for EBM. My thought was that after all these years of effort, the model for EBM was not being adopted by these recalcitrant clinicians, and and so, knowledge translation had become a new focus, another way to bring about change that must be inevitable. Mind you, I am not saying that EBM should be discarded -- far from it! -- just that my own understanding is changed, and that I will bring these thoughts to my inquiries.

* Epistemology is one of those words I have had to look up more than once, because for some reason the definition will not stay resident (I know, mind like a steel trap, eh). It's the study of knowledge, and is concerned with how knowledge is acquired.
** Sackett DL. (1993). Rules of evidence and clinical recommendations. Canadian Journal of Cardiology, 9(6):487-489.
*** Polanyi M. The tacit dimension, Peter Smith, Gloucester, MA (1966/1983).
**** Gabbay J & le May A. (2004, Oct. 30). Evidence-based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care. BMJ, 329:1013-.

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