Sandra J. Tanenbaum

Knowing and Acting in Medical Practice: The Epistemological Politics of Outcomes Research

Recent health care policymaking favors outcomes research as a response to the putative ineffectiveness, as well as the undeniable expense, of American medicine. This small-scale ethnographic study conducted in a department of internal medicine evaluates claims that probabilistic knowledge will improve clinical practice. It finds that physicians are primarily determinists and that although they reason probabilistically in some instances, they rely on personal experience over research data at these times; that doctors view outcomes research as useful but not definitive and in no way immune to the social influences on medical knowledge generally; and that their mix of determinism and probabilism is well suited to the nature of medical work. The recent ascendancy of outcomes research is as much political as scientific, empowering the research community relative to practicing physicians, lending medical legitimacy to payer-promulgated practice guidelines, and creating additional clinical work around a false standard of medical certainty.

Pay for Performance in Medicare: Evidentiary Irony and the Politics of Value

Pay for performance (P4P) is of growing importance in the Medicare program. Pay-for-performance policy has the support of political actors in both parties and in the legislative and executive branches; of experts, business, and consumer interests; and in a qualified way, of health care providers. The evidence that P4P improves quality or reduces cost, however, is scant, although P4P proponents claim that the program is evidence based. This article reviews the history of Medicare P4P, documents its widespread support, and evaluates both the evidence of its effectiveness and the expert discourse about that evidence. The article analyzes the political reasons for Medicare P4Ps popularity despite its evidentiary deficiencies and emphasizes its role in the politics of value. Pay for performance allows Medicare policy makers to (1) reformulate intractable cost and quality problems as more malleable value problems; (2) offer an acceptable quid pro quo for payment negotiations with providers; and (3) reach a rare, if shallow, consensus based on the ideological ambiguity of P4P.

Consumer perspectives on information and other inputs to decision-making: implications for evidence-based practice.

This study is an exploration of mental health consumers’ perspectives on information, including scientific information, and on other inputs to decision-making. Four focus groups were held with severely mentally ill consumers at two sites in the summer of 2005. Consumers varied in age, race and diagnosis. Participant responses were coded by theme and into subthematic categories. Implications for evidence-based decision-making included that: consumers desire and seek information about their illnesses and the mental health system; consumers identify scientific studies as information with special and welcome properties; and consumers also identify other influences on their decision-making, most of which fall under the “recovery” rubric.

Reducing Variation in Health Care: The Rhetorical Politics of a Policy Idea

For decades, geographic variation in the use and cost of health care has captured the imagination of researchers and policy makers. As a policy problem, variation suggests its own solution--reducing variation--but the substantive weaknesses of this policy idea invite a second look at its success. This article considers the politics of policy ideas to analyze the potential rhetorical strengths of reducing variation. It finds that this idea appeals to multiple health care audiences, remains practically and politically ambiguous as to problem and solution, and resonates with long-held aspirations of policy elites, including being hopeful about solving the seemingly intractable problems of the US health care system.

Perspectives on evidence-based practice from consumers in the US public mental health system

RATIONALE, AIMS AND OBJECTIVES Evidence-based practice (EBP) is a matter of mental health policy in USA. Supporters find it useful in two forms, as generating a list of approved practices and as providing information to practitioners and consumers engaged in shared decision making. Almost nothing has been written about consumer perspectives on EBP. Given that they play an important role in the second form of EBP, this study explores the range and logic of these perspectives and of related views about the role of information in decision making. METHODS Four focus groups (n = 38) were held in two settings in a Midwestern state in 2005. Thirty-nine face-to-face semi-structured interviews were conducted at three settings in 2006. Focus group members and interviewees were seriously mentally ill consumers in the public mental health system. Focus group sessions and interviews were audiotaped and transcribed. Thematic categories and subcategories were analysed. RESULTS Focus group members and interviewees varied among themselves and between groups in their responses, but three major thematic categories emerged in both groups - consumers have positive and negative attitudes towards evidence; consumers seek and receive information from multiple sources; and consumers have competing and complementary principles for decision making. Interviews revealed that although real shared decision making is rare, consumers want to and may be involved in decisions about their care. CONCLUSIONS EBP per se has mostly by-passed consumers in the public mental health system, but at least some want to be better informed about and more involved in their care. Their misgivings about evidence are reasonable and resonate with the principles of the recovery movement.

The role of "evidence" in recovery from mental illness.

Evidence-based practice (EBP), a derivative of evidence-based medicine (EBM), is ascendant in the United States’ mental health system; the findings of randomized controlled trials and other experimental research are widely considered authoritative in mental health practice and policy. The concept of recovery from mental illness is similarly pervasive in mental health programming and advocacy, and it emphasizes consumer expertise and self-determination. What is the relationship between these two powerful and potentially incompatible forces for mental health reform?This paper identifies four attempts, in the mental health literature, to delineate the role of “evidence” in recovery. One is the strong version of evidence-based practice—an applied science model—and three others address weaknesses in the first by limiting the authority of probabilistic findings. The paper also offers a fifth version, based on the concept of communicative accountability, which is derived from Habermas’ work on communicative action. The fifth version responds to the other four and emphasizes learning, disclosure and respect in clinical and other helping relationships.

Uncertainty, consultation, and the context of medical care.

Although the ascendancy of evidence based medicine obscures the uncertainty inherent in patient care, this uncertainty remains a defining fact of medical life. Griffiths et al listened to health professionals and identified three distinct approaches that were used in consultations—two of which they judged to understate the risk level of patients.1 They recommend that health professionals should be trained to communicate with their patients without recourse to the myth of medical certainty. The authors produced a distribution of approaches to consultation across several health professionals, settings, and health issues, and draw some intriguing inferences. Their findings also generate further research questions, especially …

What is Patient-Centered Care? A Typology of Models and Missions

Recently adopted health care practices and policies describe themselves as “patient-centered care.” The meaning of the term, however, remains contested and obscure. This paper offers a typology of “patient-centered care” models that aims to contribute to greater clarity about, continuing discussion of, and further advances in patient-centered care. The paper imposes an original analytic framework on extensive material covering mostly US health care and health policy topics over several decades. It finds that four models of patient-centered care emphasize: patients versus their parts; patients versus providers; patients/providers/states versus “the system”; and patients and providers as persons. Each type is distinguishable along three dimensions: epistemological orientations, practical accommodations, and policy tools. Based on this analysis, the paper recommends that four questions be asked of any proposal that claims to provide patient-centered care: Is this care a means to an end or an end in itself? Are patients here subjects or objects? Are patients here individuals or aggregates? How do we know what patients want and need? The typology reveals that models are neither entirely compatible nor entirely incompatible and may be usefully combined in certain practices and policies. In other instances, internal contradictions may jeopardize the realization of coherent patient-centered care.

Improving the quality of medical care: the normativity of evidence-based performance standards

Poor quality medical care is sometimes attributed to physicians’ unwillingness to act on evidence about what works best. Evidence-based performance standards (EBPSs) are one response to this problem, and they are increasingly employed by health care regulators and payers. Evidence in this instance is judged according to the precepts of evidence-based medicine (EBM); it is probabilistic, and the randomized controlled trial (RCT) is the gold standard. This means that EBPSs suffer all the infirmities of EBM generally—well rehearsed problems with the external validity of research findings as well as the inferential leap from study results in the aggregate to individual patient care. These theoretical weaknesses promise to have a practical impact on the care of patients. To avoid this, EBPSs should be understood as guidelines indicative of average effectiveness rather than standards to be applied in every case.

Mental Health Consumer-Operated Services Organizations in the US: Citizenship as a Core Function and Strategy for Growth

Consumer-operated services organizations (COSOs) are independent, non-profit organizations that provide peer support and other non-clinical services to seriously mentally ill people. Mental health consumers provide many of these services and make up at least a majority of the organization’s leadership. Although the dominant conception of the COSO is as an adjunct to clinical care in the public mental health system, this paper reconceives the organization as a civic association and thereby a locus of citizenship. Drawing on empirical research on COSOs in one state and the citizenship and civic democracy literatures, COSOs are analyzed here as membership organizations with democratic norms and strong ties to local communities. The suggestion is made that by embracing and enhancing their status as civic associations, COSOs may advance the goals of the social movement that spawned them and avoid predictable obstacles to further growth and development.