Posted by: ayrshirehealth | July 13, 2012

Systematic doubt – let’s facilitate it. By @austynsnowden

Some people are scientists

Professor John Atkinson, my PhD director of studies retired this week. I will miss him greatly. He was a free thinker of profound originality, and inspired in me a desire to generate questions in a robust manner. This was never activity for its own sake. John’s work for example improved the life of people as diverse as homeless men in Glasgow and pregnant women in Malawi. In other words he showed that genuine inquiry leads to important ethical output. He also showed me that genuine inquiry begins with stripping back unhelpful assumptions. At its most extreme this reduces to the following interrelated premises:

  1. I have no idea what’s going on
  2. Neither does anybody else

These are not unique statements I know. Descartes started from a similar point and built modern dualistic thinking from the premise ‘I think therefore I am’.

Personally I don’t think he went far enough in that he assumed an ‘I’ to be thinking. ‘There is a thought’ might have taken us down a different path. Instead, his separation of mind and body has got us into all sorts of trouble(1).

Nevertheless the more general point is that modern philosophers and scientists tend to implicitly share a genuine desire for systematic enquiry into real world problems.

The best science involves suspension of belief, coherence between method and knowledge claims, and reliance on evidence to drive further inquiry (2).

Some people are not scientists

However not everybody thinks like John, these people inspire in me both envy and fear. I’m envious because certainty seems to provide them with a degree of comfort to which I am excluded. I’m fearful because people exhibiting certainty clearly haven’t grasped that actually, when it boils down to it, they have no idea what’s going on either. This is particularly problematic where these people claim to recognise and treat lack of insight in others.

This is a plea for listening, not a cheap shot at psychiatry. I spent 20 years of my clinical career in the field of mental health care and recognise distress when I see it. I also recognise and support the need to do something about it. My problem is with the balance of certainty as it relates to what to do about distress in general. Thinking you know what’s going on is a precursor to recommending a course of action. Absolutely fair enough, but if you are not in possession of all the relevant facts then how likely is a positive outcome? The answer is not very, if you consider that 50% of all prescriptions are not taken as prescribed (3).

So what would John do? My impression is that he would listen carefully, he would look for the missing data to improve the situation.

Generating the missing data

To stick with the example of poor adherence to prescriptions, what data are needed to better understand this? Of course the issue is multifaceted, but a significant factor is certainly the degree to which people feel listened to within a consultation (4). Given that even well educated affluent people struggle to communicate during clinical consultations it is reasonable to assume that a power imbalance persists and that this is not helpful (5).

My personal favourite idea is the ‘tripadvisor’ solution for health services. I’ve heard quite a bit about this recently, and so I think it is safe to say it is on its way. Various services have already hosted such ventures. For example there is this initiative for rating GPs There is also the NHS choices site.

However this is a bit like the banking sector policing itself. What’s really needed therefore is for a genuinely independent view. Scientists call this eliminating bias. Imagine if you could see whether your imminent appointment was with a five star or one star service in the eyes of your fellow patients. Further, we could subsequently correlate adherence rates with patient satisfaction ratings to provide evidence that being listened to impacted on measurable health outcomes.

Health boards love this sort of data. They can make league tables out of it. But what would clinicians think? I’d like to hear from you. My hypothesis is that the scientists among you would welcome the challenge of integrating such data. More importantly, sub five star services might subsequently start to listen a bit more. They might not, but it’s a testable hypothesis.

John would approve

Generating pertinent data aimed towards improving services is something I know John would approve of.

References used in this blog.

1.            Blackmore S. Conciousness: An Introduction. 2nd ed. London: Hodder Education; 2010.

2.            Snowden A, Atkinson J. Concurrent analysis: a pragmatic justification. Nursing Philosophy. 2012;13:126–41.

3.            National Institute for Health and Clinical Excellence. NICE Full Guidance 76 – Medicines Adherence : involving patients in decisions about prescribed medicines and supporting adherence Full Guideline January 2009 National Collaborating Centre for Primary. 2009.

4.            Latter S, Sibley A, Skinner TC, Cradock S, Zinken KM, Lussier M-T, et al. The impact of an intervention for nurse prescribers on consultations to promote patient medicine-taking in diabetes: a mixed methods study. International journal of nursing studies [Internet]. 2010 Sep [cited 2011 Jun 6];47(9):1126–38. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20211467

5.            Frosch DL, May SG, Rendle KAS, Tietbohl C, Elwyn G. Authoritarian physicians and patients’ fear of being labeled “difficult” among key obstacles to shared decision making. Health Affairs [Internet]. 2012;31(5):1030–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22566443

Dr Austyn Snowden is Reader in Mental Health at UWS

Next weeks blog comes from Eddie Docherty, Nurse Consultant and focuses on putting the ‘expert’ back into ‘expert practice’.

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Responses

  1. Fabulous blog Austyn. We will all miss John’s wisdom, compassion and common sense approach to the complexities of working and personal life. Academic and clinical practice need more integrative models of the sort you mention – the themes from the Ayrshire Health blogs are full of examples.

    • Thanks Craig, he was a one off wasn’t he? I think he would be heartened by this venture. Always hard to know though, which is why it was always educational asking.


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