Wednesday, 22 March 2017

The 'otherness' of research in clinical practice

“Researchers don’t know what it’s like to deal with patients”. Research is meaningless to me – I know what works”. “Most research is rubbish.” I am concerned by comments about research that suggest it is something that can be separated from clinical practice – something that can be ignored when providing good clinical practice. I know several colleagues who just ‘don’t bother’ with research. This ‘otherness’ of research is a fallacy. It would not be so easy to distance oneself from research if we simply called it what it is: science.

Most researchers consider themselves scientists. They work under the rules of science and follow the goals of science – to find out the best estimate of the truth of how stuff works and why stuff is.
The ‘otherness’ of research (compared to clinical practice) struck me recently in a conversation with a large health group. We were discussing the implementation of a new model of care. I commented that this would be a great opportunity to do some research to find out if the model of care actually made people better. We were getting along fine until I mentioned the “R” word. They quickly looked over their shoulders and made sure the door was shut and that no-one was listening before they spoke again: “We don’t use that word here”.

It seems that research for this organisation is a no-no. It likely conjures images of meddling professors who want to tell people like them how to do things. These academics will insist on doing it the hardest way. It will take a long time and cost a lot of money. They may go off on a tangent and take control of the project. It was made clear to me that this organisation didn’t ‘research’ their projects, they ‘evaluate’ them. I persisted.

“Do you want your evaluation to give you a reliable and accurate estimate of how effective your project is?” I said. “If you do, you will need measure the right things, accurately and objectively and to design your study and analyse the data in a way that will minimise any error. That’s science – it’s the best way we currently have to measure the effectiveness of any intervention. Some call it research.” They agreed to my plan, but only if I called it ‘evaluation’.

Same deal with clinical practice. We have to make decisions all the time on what procedure to do, how to do it, what devices to use, or whether to do it at all. That knowledge is based on the highest quality (least wrong) evidence available. For some decisions, that evidence may consist only of what you have been taught, discussed with others or what you have seen yourself, but not always. Often there is better evidence that didn’t come from your practice. It is our responsibility to be aware of it, and to give it appropriate weight in our decision making. To rely only on our personal experience and that of our close colleagues is not to adequately challenge one’s beliefs by considering all the evidence. It is to be unscientific and therefore to make one’s decision less reliable and less likely to be true.


The bottom line
If research goes against your practice, it presents you with a great opportunity. Challenging your own beliefs and trying to prove yourself wrong (a technique used by Charles Darwin) is a win-win: you either strengthen those beliefs and continue good practice, or change them and improve your practice. Make science part of your practice, not part of something else.

2 comments:

  1. So sad. Thank you for being part of the solution. My day job is as a "researcher", although I think I might start calling myself a scientist. I don't usually as my background is engineering. However I am also a remedial massage therapist and teach myotherapy students research methods. It is one of my favourite bits of life. I love getting them to see the link between their assess-treat-reasess clinical paradigm with big "R" research.

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  2. Incentive-caused bias. "Both in one's own mind and that in one's trusted advisor ... It causes perfectly terrible behavior. Take sales presentations of brokers of commercial real estate businesses. I'm 70 years old and I've never seen one that I thought was even within hailing distance of objective truth." Charlie Munger

    Physicians are biased by the incentive system- Surgeons get paid when they do surgery. Oncologists, retinal surgeons, rheuamtologists get a percentage of the chemotherapy/biologicals they inject. Incentives trump science/research!

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