Abstract
BackgroundAs a response to the criticisms evidence-based practice currently faces, groups of health care researchers and guideline makers have started to call for the appraisal and inclusion of different kinds of knowledge in guideline production (other than randomized controlled trials [RCTs]) to better link with the informal knowledge used in clinical practice. In an ethnographic study, Gabbay and Le May showed that clinicians in everyday practice situations do not explicitly or consciously use guidelines. Instead, they use mindlines: collectively shared, mostly tacit knowledge that is shaped by many sources, including accumulated personal experiences, education (formal and informal), guidance, and the narratives about patients that are shared among colleagues. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing.ObjectiveThe aim of this study was to explore how informal knowledge and its creation in communities of clinicians can be characterized as opposed to the more structured knowledge produced in guideline development.MethodsThis study included a qualitative study of postings on three large virtual networks for physicians in the United Kingdom, the Netherlands, and Norway, taking the topic of statins as a case study and covering more than 1400 posts. Data were analyzed thematically with reference to theories of collaborative knowledge construction and communities of practice.ResultsThe dataset showed very few postings referring to, or seeking to adhere to, explicit guidance and recommendations. Participants presented many instances of individual case narratives that highlighted quantitative test results and clinical examination findings. There was an emphasis on outliers and the material, regulatory, and practical constraints on knowledge use by clinicians. Participants conveyed not-so-explicit knowledge as tacit and practical knowledge and used a prevailing style of pragmatic reasoning focusing on what was likely to work in a particular case. Throughout the discussions, a collective conceptualization of statins was generated and reinforced in many contexts through stories, jokes, and imagery.ConclusionsInformal knowledge and knowing in clinical communities entail an inherently collective dynamic practice that includes explicit and nonexplicit components. It can be characterized as knowledge-in-context in practice, with a strong focus on casuistry. Validity of knowledge appears not to be based on criteria of consensus, coherence, or correspondence but on a more polyphonic understanding of truth. We contend that our findings give enough ground for further research on how exploring mindlines of clinicians online could help improve guideline development processes.
Highlights
Knowledge in Health Care, Guidelines, and Evidence-Based MedicineThe processes we use for generating, validating, and disseminating medical knowledge through clinical guidelines face growing criticism
We contend that our findings give enough ground for further research on how exploring mindlines of clinicians online could help improve guideline development processes. (J Med Internet Res 2018;20(2):e34) doi:10.2196/jmir
The mismatch between the knowledge captured in guidelines and the knowledge needed for clinical practice does not appear to have been anticipated by the pioneers of evidence-based medicine (EBM)
Summary
Knowledge in Health Care, Guidelines, and Evidence-Based MedicineThe processes we use for generating, validating, and disseminating medical knowledge through clinical guidelines face growing criticism. The mismatch between the knowledge captured in guidelines and the knowledge needed for clinical practice does not appear to have been anticipated by the pioneers of evidence-based medicine (EBM) They argued that clinical expertise and patient preferences should be “integrated” with best research evidence [3]. Contrary to how some critics depicted EBM , “best” evidence was not considered to be synonymous with a simple and restrictive hierarchy of evidence, as some clinical questions are best addressed using study designs other than RCTs or because there are some questions for RCT evidence that is impossible to obtain or unavailable [4] Despite this early call for a pluralist approach to evidence in guideline development, standards and checklists for assessing the quality of guidelines (notably the Grading of Recommendations Assessment, Development and Evaluation recommendations [5]) can sometimes depict an overly hierarchical approach, inadvertently privileging RCTs even when these are not appropriate and making it difficult to give appropriate weight to knowledge from non-RCT study designs. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing
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