Summary of Inaugural Advanced Studies Seminar for
‘Norms of Belief and Norms of Action in Clinical Practice’
2 November 2017, St Catherine’s College, Oxford
In the following Summary, key insights from the discussions throughout the day are broken down by session. A Seminar overview, including follow-up initiatives is available for consultation in the Report on this event.
Introductory session by Lubomira Radoilska and Ashok Handa
Set out co-production framework, provided background to the emerging partnership and call for wider collaboration in the light of two challenges: 1) dismissing guidelines as irrelevant to practice and 2) forsaking professional judgment for procedural compliance.
Put forward the aims and objectives of the Programme: 1) raise awareness of the under-explored conflicts between norms of belief and norms of action that might feed into the two challenges and 2) develop a collaborative platform for action to constructively address these challenges by building on conceptual work by Radoilska and clinical work by Handa.
Norms of Belief and Action by Lubomira Radoilska
Articulated a new ‘two-way connection’ model of how norms of belief and norms of action relate to each other: it is appropriate to get it right by succeeding, not only to succeed by getting it right. The new model contrasts with two existing models: 1) ‘one-way connection’ from belief to action and 2) no meaningful connection between the two.
The Q&A explored ways in which the new model can help uncover and address potential conflicts between norms of belief and action in clinical practice. The implicit understanding of what counts as success in a professional role might vary with the standpoint from which the assessment is made. Failure to appreciate this might lead to the exclusion or underrepresentation of relevant beliefs. Similarly, an exclusive focus on evidence might undermine the significance of lived experiences, reinforcing a narrow and unhelpful understanding of what counts as evidence.
Norms of Behaviour in Surgery by Ashok Handa
Highlighted changing norms of behaviour for surgeons: move away from a traditional model of authority without checks toward a more balanced distribution. The Mortality and Morbidity meetings in surgery help develop norms of learning from own mistakes.
At the same time, however, the Evidence pipeline is ‘leaky’: only ~10% of good practice turns into everyday practice. A lot of good practice does not get published or doesn’t get noticed by relevant readers. Further difficulties of implementation include: 1) ‘cherished beliefs’ of practitioners, 2) novelty of gadgets, 3) little time to discuss cases even in values-based decision-making.
Dialogue with patients is crucial. The question ‘What would you do doctor [in my situation]?’ can be answered by a surgeon either from their own standpoint or from the standpoint of the patient who is likely to have different values, commitments and concerns.
Dialogue with all healthcare professionals involved is also crucial. It helps avoid the ABCDE of bad behaviours by Chief Surgeons: Accuse – Blame – Criticise – Demoralise – Exonerate (oneself at the expense of the team). A challenge in this respect is how to transcend dialogue situations which, although multi-professional, remain one-perspectival.
Practical Reason and Ecological Thinking by Nancy Nyquist Potter
Identified damage done by mainstream epistemology to people who are not listened to. Forms of epistemic injustice affecting the credibility of marginalised populations. There are also actions expressing hope and confidence.
Mainstream epistemology relies exclusively on a third-personal account of knowledge and competence. The two-way connection model proposed by Radoilska goes further to integrate a first-personal perspective. Still, there is need to do justice to the second-personal aspect of knowledge. This can be achieved by a new account of practical reason and ecological thinking. It builds on the notion of ecological thinking introduced by Lorraine Code to designate strategies for knowing well within enacted practices. Learning how to listen well is an important aspect.
Further elements include the notions of aliefs, introduced by Tamar Gendler, and affects, by Lisa Tessman. Aliefs are neither irrational beliefs, nor desires. They are associative and non-propositional. Their interest is to draw attention to instances, where belief and behaviour are mismatched. By contrast, affects are alarm-bell emotions. They not only point to instances where reason and emotion are at odds. They also show how and why this kind of emotion is very likely to override reason.
Like any new epistemology, the ecological model faces the danger of co-optation within a system of reified norms. To resist this, criteria for rationality should be open to contestation. This is not to reject strong objectivity. Shared reality grows out of openness to criticism. Otherwise new forms of epistemic injustice are generated.
The ecological model is well-suited to clinical practice. It makes space for service users to be heard and their experiences understood. Its focus on advocacy and believability strengthen the role of personal experiences as opposed to impersonal data. The overarching aim is to support communities that cut across stereotypes and reduce stigma.
OxAAA – Progress through Partnership by Ismail Cassimje
Outlined the rationale for and development of Progress through Partnership, an initiative of OxAAA (Oxford Aortic Aneurysm Awareness) Group.
The Partnership builds on the insight that basic science is very far from a patient’s lived experience. The OxAAA started a Newsletter to inform patients and the wider community about recent developments in clinical practice and underpinning research. Engagement days where patients and their families can learn more about the condition, possible interventions and ways to improve health outcomes are well-attended and appreciated.
Feedback from these events and further communications by the OxAAA team is very encouraging. It shows that patients are willing and able to engage actively in shared decision making. They are open about and reflect on their experiences. For instance, most patients did not consider aneurysm to be a disease at the start of consultation. Yet, they had clear views on focus for future research, which didn’t just follow those of researchers or clinicians. These interactions also revealed the role of different cultures and power hierarchies, in which patients participate outside the clinic. Taking this wider context into consideration may be difficult, but is nevertheless crucial to a values-based clinical practice.
Focus Group Work
We divided into 4 groups each focussing on a specific area where the Programme on ‘Norms of Belief and Action in Clinical Practice’ might achieve significant impact. In this context, four questions were considered:
1) In what ways can the Programme be relevant to this area?
2) How can its introduction be supported/facilitated?
3) What are the main challenges to introducing the Programme?
4) Are there specific cases where the Programme can be particularly helpful?
Feedback from focus groups was then gathered and explored further in a general discussion.
Working with guidelines
1) The Programme could offer a helpful way of interrogating guidelines and revisiting standard expectations from implementation.
2) Integration within CPD would be a natural path for achieving most impact.
3) Anxiety from using own judgment. Fear of litigation. Different perspectives.
4) Surgery is a good example to demonstrate how the Programme can make a positive difference, e.g. by fostering a sense of multidisciplinary and multi-perspectival decision making and developing common beliefs, including about what success means within a practice.
Feedback from Practice to Policy
1) The Programme can help address a key challenge about implementing policy into practice: guidelines are designed to promote consensus; yet, practice is plural, and disagreement is rife.
2) Inclusion into Good Practice. Not just new guidelines, but a new circular model of implementation, such as feedback loop with practice and evidence as a starting point. Policy is created to address the challenges identified. In turn, practice changes to reflect new policy. Feedback is then gathered and interpreted to revise policy as and when required.
3) Concern about loss of accountability. Often negative angle of regulatory frameworks, e.g. how to enforce minimal standards and pre-empt bad practice.
4) Policy, both overt and covert is a process of consensus-making. Dissent in practice should be given greater visibility. Creating a listening culture where all participants are valued as co-producers. Development and facilitation of language across different cultures.
Shared-decision making
1) The Programme can help challenge unspoken assumptions about what makes an intervention successful. Is it time-saving? Or health outcomes? Or patient involvement? It could facilitate explicit acknowledgment of different perspectives so that less powerful participants are also heard and understood.
2) Recognising dissonance with existing models. Making room for beliefs and commitments beyond evidence-based practice. Disagreements about the problem not only about the solutions.
3) Lack of awareness of how extensive unexpressed disagreements are. Assumed or enforced consensus because of efficiencies and resources constraints. Outcomes are often pre-decided and communicated in advance rather than set out together, in dialogue with patients. The experience of being alienated and dehumanised in healthcare settings.
4) Bringing to the fore the interpretive element of clinical interactions. Different ways of seeing what happens can and should be tolerated. Articulating, understanding and challenging the beliefs underpinning different narratives. Acknowledging people’s presence. Building a rapport.
Professional judgment
1) The Programme could be relevant to cases where a health professional’s belief system doesn’t work. It helps explain why it is legitimate for them to trust own practice instead of holding onto common but useless beliefs.
2) Clearer real-life examples. The normative framework should be illustrated with case studies.
3) Difficult theoretical apparatus. Philosophical ideas can be challenging and require careful translation to find their way into clinical practice.
4) Improving patient experience. A good example is therapeutic lying. It started as intervention based on professional judgment, beyond following guidelines. It was done to spare a person with Alzheimer’s reliving the trauma of bereavement every time she was reminded of her husband’s death. This professional judgment was accepted as good practice by fellow clinicians. It was subsequently included into the new guidelines on how to treat patients with this condition.
Concluding remarks by Lubomira Radoilska
Thanked Seminar participants for their contributions to the Programme, recapped key insights from the discussions and set out a provisional timeline for future work, the next steps being the creation of a website to facilitate co-production and the circulation of materials resulting from the Seminar, including a Summary and a Report.
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