How doctors ask, how doctors think

Sue Spurr is a part time PhD student at the Open university looking at the experiences of CAM practitioners moving from training into practice.  Here she tells the story of some sessions at the Royal College of Physicians 'patient agenda' conference last December.

‘Being guided by patient narratives’ Dr John Launer, The Tavistock and Portman NHS Foundation Trust, London.

A compelling and fitting opening to the conference, Dr John Launer set the scene in speaking about ‘being guided by patients narratives’.

His approach to his patients is to be an ‘attentive, curious listener’ in order to be a ‘co-author’ in generating patients’ stories and as a consequence – crucially -  they will tell you their diagnosis, possibly within fifteen minutes.

The central idea is that patients create their own realities by putting them into a form of words which have their own kind of internal logic.  Given the right kind of listening and questioning, the stories can change for the better.

Dr Launer has spent the last fifteen years encouraging GPs to stop trying ‘to extract’ information and ‘getting to the bottom of things’ (whether there is indeed such a thing). Sometimes advice is necessary and of course, there are occasions eg where there is an acute situation, when the doctor needs to act quickly.

However, stories will not emerge if the doctor or practitioner sees every situation as an acute situation, as the patients will stop ‘co-authoring’. Dr Launer argues that if we, as practitioners, can ‘let go of our own inner tyrannies’ eg need for control and interpretation, then patients will tell you their diagnosis. 

It’s like weaving a ‘conversational tapestry; they put in a thread, we put in a thread and what emerges is something unique and can take less than fifteen minutes’.

‘Evidence-based mind-lines (how doctors actually make decisions in practice)' Professor Andrée le May, University of Southampton

Professor Andrée le May brought into focus the question of how does clinical knowledge actually get used in practice?

She suggests that practitioners do not tend to use evidence directly from research ie there is little direct translation of new knowledge to practice. 

What happens, she suggests is that practitioners rely on ‘mindlines’ or ‘collectively reinforced, internalised, tacit guidelines’ for guiding their practice. Mindlines are ‘constructed, shaped and sustained by contextual demands, opportunities and constraints’.

Individuals tend to work and learn collectively (eg in communities of practice). A key point is how knowledge is not so much translated but transformed, by a process of co-producing knowledge-in-practice.

Professor le May suggests that an important emerging implication is that knowledge translation needs  to ‘start by understanding the recipients as active agents who are continually co-producing their collective mind-lines’.