Thursday, December 20, 2007

shaped 'for good'

Annemarie Mol's Keynote address at the 11th annual qualitative research conference provides the basis for this blog.
Instead of the random control trial (rct) being the gold std to prove that care practices studied are good, we would do better to develop research methods that work to improve care practices. She argues against foregrounding effectiveness but instead that we investigate the various effects of interventions. The effects on the bodily parameters and on the intricacies of daily life should not be separated out but studied in connection.

Now here lies a good idea because the faults in studying effectiveness are numerous. Through reading several horrible articles i have learned how to survive 'best practice.' The following articles should come with warning that they may be damaging to your health:
'Best Practice' for restraining people
(Evidence Based Practice Information Sheets for Health Professionals. Volume 6, Issue 3, 2002 ISSN 1329 - 1874 Physical Restraint -Part 1:
Use in Acute and Residential Care Facilities)
'Best Practice' in wound care demonstrating potable water is good enough for wound care
(Evidence Based Practice Information Sheets for Health Professionals. Volume 7, Issue 1, 2003 ISSN 1329 - 1874 Solutions, Techniques and Pressure for
Wound Cleansing.)

These articles, widely disseminated, fail to take into account
1. the purpose of care
2. not doing harm (saline doesn't hurt, water does).

Mol discusses this because what is 'for the better' is often not known.
This reading -in combination with it being Christmas and my having a pine tree in my lounge- reminds me of other reading, of E.M. Rogers, and of how the repercussions of change are oftentimes unexpected. p440 a story of Lapps and loss of reindeer and establishing a culture of dependence and poverty following the introduction of snowmobiles.
The effects of adopting innovations are oftentimes not known in advance, and maybe shouldn't wait for full implementation and formal evaluation before being revisited.

Effective and good practice are not unequivocal- Mol draws on examples from arteriosclerosis treatments and of type 1. diabetes.
She demonstrates how control needs to be social and material.
I remember a friend who killed herself. She too had type 1 diabetes, but she also had genital herpes. The diabetes would go out of control whenever the herpes flared up. Living between metabolic wards and gynae wards and the mental health unit for most of a year, she decided if this is life it sucks. Such control needed in her life made life unlivable. She killed herself.

Mol questions the notion of the good, 'what is good care?' Is the management so tight it risks hypoglycamia? This risks relationships as it tends to make people aggressive. There is a concurrent risk to brain cells; hypoglycaemia kills brain cells. The body and the social are implicated throughout. She concludes we cannot tell what good health care is, not simply, not in general. And so argues that it has to be established closer to home: in practice- in day to day life.

I concur.

If what is good care cannot be answered in effectiveness measures, an urgency still remains in providing an evidence base for practice. It is not a case that one treatment is better than another, as they come with different 'goods' and 'bads', qualitatively. How then to handle these? If there is trade off long term vs short term, what is more important? What is it you- as client- need /want to achieve...?
Clinical trials have a tendency to evaluate what is, what exists, what is known and market conditions support this. She argues though, that the market alone is not enough to improve health care. Treatments do not suddenly materialize of themselves. and treatment options are not linear. Goals+treatment+evaluation is not the only care trajectory that can or does unfold. The devil may be in all the details, but people are not automatons, almost every variable in a person's life is subject to change. Professional care involves tinkering, negotiating, and 'doctoring' to fit.

She further argues that this becomes obvious over time and not in snapshots or vignettes. The rct evidence to convince of best options, of funding, of external persons, of outsiders, of the quality of existing care, would do better to focus on insider issues. In tinkering and adapting, in calibrating. Such research is not in prooving rightness or wrongness but adaptability, of improving practices. Such unravelling of the tensions involved.

I wish i had written this myself. She's clever.
To further paraphrase:

A lot goes on without being sharply articulated, this then is our job as researchers: to unravel and to articulate, casting practice into words that allows them to travel, so that they might be more widely reflected on. Reality becomes foregrounded, and the intricacies of hopes and fears negotiated alongside the material technologies involved. The sociotechnical comes as a package, so it is better to study them together. In doing so we may come to discover how one form of practice differs from another, how practice is shaped 'for good.'

I am in awe.
I am not studying effectiveness of counselling in its various forms, but i am studying practice; practice as it unfolds and is un/told.


  1. Inspirational! Where can I find the full text of this? Amazing! I <3 Mol!

  2. Hi Paul,
    i chanced on it in a backlog of reading. I am just catching up again now that the academic/teaching year is over.
    A link on her name Annemarie Mol should work now also.

  3. Thanks for the pickup.