In reply
Article Outline
The Working Group doth protest too much, methinks1 and the volume of their response confirms that academics who criticize the academy put themselves at risk.2 However, I fear they have missed the main point.
The motivation for my comments was not to oppose scientific progress, or to yearn for a lost paternalism, or any of the other several assertions made, but rather a fairly simple observation: that knowledge translation seems to be more push than pull, more the research community delivering its product than practitioners seeking it. As a social phenomenon, knowledge translation has been an activity of academics, not practitioners. One might think of it as a marketing effort for a product that we all agree has not been as successful in the marketplace as we had hoped. This situation suggests one (or more) of 3 possibilities: either the customers (clinicians in practice) have not heard our message; or, they have heard the message but have not been able to act on it due to a variety of barriers; or, the product isn't very good–from the viewpoint of the customer and only the customer. Drs. Lang et al correctly point out that some very good work has been done addressing the first 2 possibilities3, 4 but the third issue has not been explored, because the product is assumed to be good if it meets the researchers' standards. I think it would be more useful to address the third question from the viewpoint of the customer, and to do that we need to explore the differences between their perspectives. Dr O'Shaughnessy's response plaintively addresses this gap between points of view.
The reason for the gap is that practitioners and researchers approach the same topic from different philosophical and scientific paradigms.5 The dominant paradigm5 of scientific activity held by researchers stems from positivism, and it clashes with the uncertain, pragmatic realities of clinical activity. The positivist perspective has led the research community to be devoted not to the production and distribution of fundamental knowledge in general, but rather to a particular view of knowledge that fosters selective inattention to practical competence and knowledge-in-action. Unfortunately, these types of practical but difficult-to-articulate activities are essential to professional practice, but are puzzling anomalies that do not fit the positivist paradigm, and thus are discounted if not discarded.6 The problem is exacerbated by the tendency of the practice community to express itself in terms of intuition or “the art of medicine,” terms which tend to close off rather than open up discussion; and exacerbated again by the tendency of post-structural, non-positivist philosophies of science to stress the proliferation of meanings, the breaking down of existing hierarchies, the shortcomings of logic, and the failures of analytical approaches–elements that may strike modernist scientists as subversive or even destructive.7 This is unfortunate, because a thoughtful discussion of the appropriate roles and potential values of the positivist versus the interpretivist paradigms in clinical work is, in my opinion, one of the most important intellectual issues in medicine today.8 A post-structural research paradigm might narrow the gap in perspectives by leading to a philosophy of science focused more on practical results and their implications, grounded in the clinical workplace, and less on the generation of abstract meta-narratives serving to establish legitimacy.7 That is, to research directed less at producing universal, abstract, conceptual truths, and more at local, timely knowledge of particular, concrete situations that can serve as reasonable guides for action for Dr O'Shaughnessy and her colleagues.2
It would seem important to begin a dialogue on how or whether shifting our paradigm might help both academics and practitioners. Such a discussion obviously cannot be held within the existing paradigm, but given sufficient openness to new thinking, it could help illuminate when and where new (or old) approaches are either useful or limited.
References
- Shakespeare W. Hamlet, the Prince of Denmark. Act 3, scene 2, line 230.
- . Return to Reason. Cambridge, MA: Harvard University Press; 2001;
- Cognitive and social issues in emergency medicine knowledge translation: a research agenda. Acad Emerg Med. 2007;14:984–990
- Why don't physicians follow clinical practice guidelines? (A framework for improvement). JAMA. 1999;282:1458–1465
- . The Structure of Scientific Revolutions. Chicago, IL: University of Chicago Press; 1970;
- . The Reflective Practitioner: How Professionals Think in Action. New York, NY: Basic Books; 1982;
- . Complexity and Postmodernism: Understanding Complex Systems. London, UK: Routledge; 1998;
- . The limits of techne and episteme. Ann Emerg Med. 2004;43:15–16
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
PII: S0196-0644(08)00433-2
doi:10.1016/j.annemergmed.2008.01.341
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Finding One's Way In Translating Evidence Into Practice
- Making Change in the Emergency Department
