Wieringa Sietse, Engebretsen Eivind, Heggen Kristin, Greenhalgh Trisha
Evidence-Based Health Care Program, Department of Continuing Education, University of Oxford, Oxford, United Kingdom.
Department of Health Sciences, University of Oslo, Oslo, Norway.
J Med Internet Res. 2018 Feb 2;20(2):e34. doi: 10.2196/jmir.8325.
As 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.
The 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.
This 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.
The 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.
Informal 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.
作为对循证医学目前所面临批评的回应，医疗保健研究人员和指南制定者团体已开始呼吁在指南制定过程中评估和纳入不同类型的知识（除随机对照试验[RCT]之外），以便更好地与临床实践中使用的非正式知识相联系。在一项人种学研究中，加贝和勒梅表明，临床医生在日常实践中并不会明确或有意识地使用指南。相反，他们使用思维线路：集体共享的、大多为隐性的知识，这种知识由多种来源塑造而成，包括积累的个人经验、教育（正规和非正规）、指导以及同事之间分享的有关患者的叙述。在这项关于非正式知识的研究中，我们将临床医生的虚拟网络视为更广泛医疗界中思维线路的代表，视为知识的持有者以及知识产生的催化剂。
本研究的目的是探讨与指南制定中产生的结构更严谨的知识相比，临床医生群体中的非正式知识及其产生过程具有怎样的特点。
本研究包括一项定性研究，以英国、荷兰和挪威针对医生的三个大型虚拟网络上的帖子为研究对象，以他汀类药物为案例研究主题，涵盖1400多篇帖子。参照协作知识构建理论和实践社区理论对数据进行主题分析。
数据集显示，提及或试图遵循明确指导和建议的帖子极少。参与者展示了许多个体病例叙述实例，突出了定量测试结果和临床检查结果。强调了异常值以及临床医生在知识使用方面面临的物质、监管和实际限制。参与者将不太明确的知识作为隐性和实用性知识进行传达，并采用一种普遍的务实推理方式，重点关注在特定病例中可能有效的方法。在整个讨论过程中，通过故事、笑话和意象，在许多情境中生成并强化了对他汀类药物的集体概念化。
临床社区中的非正式知识和认知需要一种内在的集体动态实践，其中包括明确和不明确的成分。它可以被描述为实践中的情境知识，非常注重决疑法。知识的有效性似乎并非基于共识、连贯性或一致性标准，而是基于对真理的更复调的理解。我们认为，我们的研究结果为进一步研究如何通过在线探索临床医生的思维线路来帮助改进指南制定过程提供了充分的依据。
