Eivind Engebretsen

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Unpacking the process of interpretation in evidence-based decision making.

Evidence-based medicine (EBM) has promoted the conscientious and systematic use of the best available scientific evidence in clinical decision making [1]. From an EBM point of view, only experimental evidence, especially results from randomized controlled trials and meta-analyses of trial results, count as strong evidence. Experiential evidence based upon expert opinion is classified as weak and placed at the bottom of the evidence hierarchy. EBM is often contrasted with traditional clinical medicine which considered pathophysiological reasoning and expert knowledge as the principal sources of clinical decision making. In a recently published article in Journal of Evaluation in Clinical Practice, Jeannette Hofmeijer describes EBM as a revision of medical epistemology and points to the neglected role of expert opinion and the lack of focus on the principles of reasoning underpinning EMB [2]. More specifically, she shows how EBM involves important processes of interpretation. Hofmeijer is mainly concerned with the role of interpretation in the production of scientific knowledge within the EBM tradition, and she illustrates how the quest for evidence relies upon interpretation both in formulating a hypothesis and in accepting the accumulated evidence as sufficient. We will argue a related but still different perspective demonstrating the principles of reasoning involved in the integration of experimental and experiential knowledge in clinical decisions and the role of interpretation in this respect. The goal of EBM is, according to Sackett et al., the integration of (1) clinical experience and expertise; (2) scientific evidence; and (3) patient values and preferences to provide high-quality services [1]. However, a weakness of EBM is the lack of guidance on how to combine the main knowledge components of the model. The EBM literature says little about how to create a fruitful interaction between research, clinical expertise and patient preferences. Although the principal aim of EBM is to promote more conscientious and systematic clinical decision making, an important element of the model remains black boxed: the principles of reasoning according to which the different knowledge sources are combined. This paper aims to make explicit the often implicit interpretational work involved when scientific evidence, clinical expertise and patient preferences are combined. We believe that better awareness about this process of interpretation can promote better and more trustworthy decision making. Lack of individualization is a recurrent criticism against EBM [3,4]. Randomized clinical trials measure average effects and do not necessarily match the local and complex situation of the individual patient [5]. The need for a situated, practice-based reasoning has been argued, and concepts such as clinical intuition [6], tacit knowledge [7], wisdom [8] and collectively defined ‘mind lines’ [9] have been introduced to challenge a unilateral focus on implementing research evidence. More recently, the literature on patient-centred medicine and shared decision making has emphasized the importance of involving patients in medical decisions and suggested useful methods and approaches [10,11]. In spite of these attempts, the principles of reasoning according to which the knowledge sources are combined and applied are still poorly understood. There are few, if any, models and concepts available which make explicit the interpretational operations involved when combining and applying the knowledge components. We intend to throw light on this process by drawing on a four-step model of knowing developed by the Canadian philosopher Bernard Lonergan [12].

Uncertainty and objectivity in clinical decision making: a clinical case in emergency medicine

The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and uncertainty as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh’s taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case analysis is further developed by the use of the Canadian philosopher Bernard Lonergan’s theory about understanding and objective knowing. According to Lonergan it is not by getting rid of or even by reducing uncertainty, but by attending systematically to it and by relating to it in a self-conscious way, that objective knowledge can be obtained. The paper concludes that uncertainty is not a regrettable and unavoidable aspect of decision making but a productive component of clinical reasoning.

Has evidence-based medicine ever been modern? A Latour-inspired understanding of a changing EBM

Abstract Evidence‐based health care (EBHC), previously evidence‐based medicine (EBM), is considered by many to have modernized health care and brought it from an authority‐based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latours vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latours work, we argue that the early EBM movement had a strong modernist agenda with an aim to “purify” clinical reality into a dichotomy of objective “evidence” from nature and subjective “preferences” from human society and culture. However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition—albeit implicit and undertheorized—that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a “situated practice” rather than as a sequence of research‐driven abstract decisions.

Accreditation and Power: A Discourse Analysis of a New Regime of Governance in Higher Education

This article studies discourses within the accreditation of Norwegian higher education conducted by the Norwegian Agency for Quality Assurance in Education (NOKUT), using one concrete case (the accreditation of bachelor programs in nursing). Analysis of policy documents and accreditation reports are influenced by two of Foucaults concepts of power; governmentality and panopticon. The analysis provides insights into firstly, how the two forms of power are woven into the schemes used for quality control by redefining quality to be a quantifiable concept; secondly, how the supervision of quality gives privilege to specific types of knowledge; thirdly, how supervisory power is reformulated to require self-control mechanisms within higher education in terms of constant quality development and realization of unexploited potentials; and fourthly, how this power legitimates itself by making all parties guardians of quality control, deconstructing the difference between evaluator and evaluated.

Who cares? The lost legacy of Archie Cochrane

Over the last 20 years, the evidence-based medicine (EBM) movement has sought to develop standardised approaches to patient treatment by drawing on research results from randomised controlled trials (RCTs). The Cochrane Collaboration and its eponym, Archie Cochrane, have become symbols of this development, and Cochranes book Effectiveness and Efficiency from 1972 is often referred to as the first sketch of what was to become EBM. In this article, we claim that this construction of EBMs historical roots is based on a selective reading of Cochranes text. Through a close reading of this text, we show that the principal aim of modern EBM, namely to warrant clinical decisions based on evidence drawn from RCTs, is not part of Cochranes original project. He had more modest ambitions for what RCTs can accomplish, and, more importantly, he was more concerned with care and equality than are his followers in the EBM movement. We try to reconstruct some of Cochranes lost legacy and to articulate some of the important silences in Effectiveness and Efficiency. From these clues it might be possible, we argue, to remodel EBM in a broader, more pluralistic, more democratic and less authoritarian manner.

Legitimating the illegitimate: How doctors manage their knowledge of the prestige of diseases:

Although the sociology of medicine has developed a rich body of research on patients’ experiences and how they handle their illnesses, few analyses have examined doctors’ concepts of disease. Building on previous research findings that doctors consider some diseases to be more worthy than others, this article focuses on how these differences in disease prestige are articulated and made logical. We presented a focus group panel of doctors a table of 38 diseases rank-ordered by prestige according to the results of a previous quantitative study of doctors. We prompted a lively discussion among the doctors by asking them whether they were familiar with this rank order. In analysing how they managed the prestige knowledge presented to them, we focused on how they handled the value conflict between this informal rank order and the formal value of equality of treatment. Using positioning theory as a theoretical premise and a methodological tool, we found that the focus group participants created positions in their conversations that allowed them to present and discuss views on disease prestige that would be considered illegitimate if they were declared directly. However, they were able to do so without being forced to take a personal stand. Thus, we demonstrate how informal disease rankings can be produced and reproduced.

Protocol for a qualitative study of knowledge translation in a participatory research project.

Introduction In this article, we present a methodological design for qualitative investigation of knowledge translation (KT) between participants in a participatory research project. In spite of a vast expansion of conceptual models and frameworks for conducting KT between research and practice, few models emphasise how KTs come about. Better understanding of the actions and activities involved in a KT process is important for promoting diffusion of knowledge and improving patient care. The purpose of this article is to describe a methodological design for investigating how KTs come about in participatory research. Methods and analysis The article presents an ethnographic study which investigates meetings between participants in a participatory research project. The participants are researchers and primary healthcare clinicians. Data are collected through observation, interviews and document studies. The material is analysed using the analytical concepts of knowledge objects, knowledge forms and knowledge positions. These concepts represent an analytical framework enabling us to observe knowledge and how it is translated between participants. The main expected outcome of our study is to develop a typology of KT practices relevant to participatory research. Ethics and dissemination The project has been evaluated and approved by the Norwegian Social Science Data Services. Informed consent was obtained for all participants. The findings from this study will be disseminated through peer-reviewed publications and national and international conference presentations.

The One or the Many: Quantified Subjectivity and Aggregated Uniqueness in Qualitative Rehabilitation Research.

This article aims to identify and critically assess qualitative intervention studies of rehabilitation processes that target young adults. By applying a meta-epistemological approach inspired by the works of Michel Foucault and Julia Kristeva, we examine how the included studies present qualitative knowledge and whether they adhere to their own stated principles of qualitative knowledge. Through their stated aims and theoretical framing, the articles draw attention to individual processes of meaning making. Nonetheless, we find that the articles to a great extent emphasize frequencies of the qualitative data they present. Individual processes and experiences are subject to subdivisions and categorization and transformed into manageable objects of knowledge. In conclusion, these studies, with one important exception, contribute to self-marginalization of the knowledge they themselves promote: They undermine the uniqueness of the qualitative knowledge they proclaim by focusing on frequency and the general patterns and categories encompassing the unique.

‘Working is out of the question’: a qualitative text analysis of medical certificates of disability

BackgroundMedical certificates influence the distribution of economic benefits in welfare states; however, the qualitative aspects of these texts remain largely unexplored. The present study is the first systematic investigation done of these texts. Our aim was to investigate how GPs select and mediate information about their patients’ health and how they support their conclusions about illness, functioning and fitness for work in medical certificates.MethodsWe performed a textual analysis of thirty-three medical certificates produced by general practitioners (GP) in Norway at the request of the Norwegian Labour and Welfare Administration (NAV).The certificates were subjected to critical reading using the combined analytic methods of narratology and linguistics.ResultsSome of the medical information was unclear, ambiguous, and possibly misleading. Evaluations of functioning related to illness were scarce or absent, regardless of diagnosis, and, hence, the basis of working incapacity was unclear. Voices in the text frequently conflated, obscuring the source of speaker. In some documents, the expert’s subtle use of language implied doubts about the claimant’s credibility, but explicit advocacy also occurred. GPs show little insight into their patients’ working lives, but rather than express uncertainty and incompetence, they may resort to making too absolute and too general statements about patients’ working capacity, and fail to report thorough assessments.ConclusionsA number of the texts in our material may not function as sufficient or reliable sources for making decisions regarding social benefits. Certificates as these may be deficient for several reasons, and textual incompetence may be one of them. Physicians in Norway receive no systematic training in professional writing. High-quality medical certificates, we believe, might be economical in the long term: it might increase the efficiency with which NAV processes cases and save costs by eliminating the need for unnecessary and expensive specialist reports. Moreover, correct and coherent medical certificates can strengthen legal protection for claimants. Eventually, reducing advocacy in these documents may contribute to a fairer evaluation of whether claimants are eligible for disability benefits or not. Therefore, we believe that professional writing skills should be validated as an important part of medical practice and should be integrated in medical schools and in further education as a discipline in its own right, preferably involving humanities professors.