Evidence-based medicine (EBM), a movement that emerged roughly 30 years ago, advocates for the use of current best evidence from high quality research studies in healthcare decision making. This logical and straightforward way of delivering healthcare often fails in modern day practice. One simple reason that clinicians cannot execute point of care decision making with EBM is due to the overwhelming volume of scientific evidence that is ever changing and available within severe time constraints. A more pervasive reason is found in the way clinicians practice and incorporate knowledge into their daily work – they tend to follow what ethnographers Gabbay and Le May have coined as mindlines: collectively reinforced, iterative, internalized, and tacit guidelines. Clinicians’ practice is primarily influenced by trusted colleagues, mediated by cultural and organizational features of their practices, and is constantly refined as knowledge-in-practice-in-context.
Through my own wandering through various clinical settings, I have often heard phrases from respected clinicians including “there is evidence…and then there is actual practice.” The five part concept of EBM appears intuitively important in a science-based profession – define the problem, search for sources of information, critically evaluate that information, apply the information to the patient encounter, and evaluate the efficacy of the application of that information for that specific patient. It seems that an exciting opportunity would be data analytics enhanced by artificial intelligence that could search high volume clinical research and identify patient-matching criteria in order to assist clinician judgment on relevant treatment protocols.
How much of this is naïve rationalism? Upon evaluating a typical clinical scenario, what I used to think was a clear set of facts in a one-dimensional reality is now more like an interaction of temporary realities of patients, clinicians, researchers, and guideline/policy makers. Mindlines are therefore:
- More than intuition.
Mindlines that clinicians abide by undergo a validation process despite being mainly tacit. They are built off of shared sense-making in the local settings of patient care, which leads to coherence and negotiation with real-time environmental influences. They provide for more accuracy than the reductionist tools and beliefs of EBM.
- More patient centered.
Mindlines allow for incorporation of valid knowledge to occur from the patient’s perspective, as opposed to the paternalistic model of clinician knowing all and only being able to derive more information from EBM.
- Meaningful and effective.
Mindlines are not very far off from the way typical high performers solve problems – they consciously and unconsciously adjust their frameworks through contextual experience, colleagues, and the physical world. EBM can negotiate with these frameworks, but likely can never replace them.
The paradigm of mindlines offers insight into the way clinicians practice and how western medicine operationally works in an environment with varying expectations from the patient and the overall industry where innovative work is being attempted. The secular trend for the future hopefully will be the risk-adjusted incorporation of EBM with assistance from artificial intelligence into the tacit world of clinical medicine.