Portal de Periódicos da CAPES

Lost in Translation

2007; Elsevier BV; Volume: 51; Issue: 1 Linguagem: Inglês

10.1016/j.annemergmed.2007.06.015

1097-6760

Robert L. Wears,

Chronic Disease Management Strategies

SEE RELATED ARTICLES, P. 70 and 80. [Ann Emerg Med. 2008;51:78-79.] “Knowledge translation” is the latest in a long line of efforts to “translate research into practice,” motivated by multiple observations that clinicians’ behaviors are often unmoved by “evidence”1Freeman A.C. Sweeney K. Why general practitioners do not implement evidence: qualitative study.BMJ. 2001; 323: 1100-1102Crossref PubMed Scopus (312) Google Scholar, 2Committee on Quality of Health Care in AmericaCrossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, DC2001Google Scholar, 3Marchione M. Evidence shows sloppy stroke care in US. Available at: http://www.cbsnews.com/stories/2005/01/25/health/main669114.shtml. Accessed June 29, 2007.Google Scholar and unaffected by guidelines.4Cabana M.D. Rand C.S. Powe N.R. et al.Why don’t physicians follow clinical practice guidelines? a framework for improvement.JAMA. 1999; 282: 1458-1465Crossref PubMed Scopus (5098) Google Scholar, 5Wears R.L. Headaches from practice guidelines.Ann Emerg Med. 2002; 39: 334-337Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In this issue of Annals, 2 articles highlight different aspects of this problem. Hurley et al6Hurley K. Sargeant J. Duffy J. et al.Why are emergency departments holding back on holding chambers for children with asthma? facilitators and barriers to change.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar report an examination of the factors affecting emergency physicians’ failure to adopt the routine use of spacers and metered-dose inhalers in asthma, despite a long stream of research reports and exhortation; and Wright et al7Wright S.W. Trott A. Lindsell C. et al.Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report.Ann Emerg Med. 2008; 51: 80-86Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar report an organized attempt to develop a department-level system for the translation of evidence-based knowledge into a standardized practice system, using asthma care as an exemplar. The essence of these 2 articles, and others like them, is to ask, Why aren’t those clinicians out there paying attention to what we’re doing? This is basically an act of projection by academic medicine. Recognizing that clinicians are not eagerly incorporating research findings into their practice, researchers glibly assume that the problem could not be with the research but must lie externally, in the “resistance” of clinicians. In response to this phenomenon of resistance, universities and funding agencies send out squads of researchers and embark on change programs, to study, explain, and modify clinicians’ seemingly perverse, aberrant, and irrational behavior. But as others have suggested,8Brooks D. Kicking the secularist habit: a six step program.in: Atlantic Monthly. 2003: 26-28Google Scholar the phenomenon that actually needs explaining is the behavior of the medical professoriate; it is clinicians who should be sending out researchers to try to understand why there are pockets of people (mostly in universities) who believe that their abstractions are useful guides to a complex, highly contingent, conflicted, constrained, and messy world. The rhetoric used in these discussions bears examination; typically, the issue has been framed as “translating research/knowledge/evidence into practice/action/change.” This bears a remarkable resemblance to the rhetoric of colonialism, in which the imperialist masters expressed a perceived need to bring a simplified version of, say, western civilization to the childlike locals (who, ungratefully, seemed not to appreciate it).9Kipling R. The white man’s burden. Available at: http://www.fordham.edu/halsall/mod/Kipling.html. Accessed May 20, 2007.Google Scholar “Translation,” of course, implies that the material to be transferred is foreign, inherently different and difficult to comprehend, especially for the recipients. The implication here is that research is too sophisticated and complex for practitioners to understand directly, so there is a need to make it easy for them, to compensate for their ignorance. The possibility that it is we as researchers who are ignorant of the clinicians’ context, needs, and constraints is never raised; translation here is unidirectional. And the idea that this material needs to be “inserted into” practice (whether practice wants it or not) is, to put it gently, the rhetoric of physical violation (Leif Solberg, oral communication, January 2003). Something may have been lost in the translation of research into practice, but we should consider the possibility that it is the research community that is lost. Research fundamentally values knowledge for its own sake; practical applications are nice but not essential in the deepest sense. The desire to have practical impact is understandable but not fundamental, and trying to force impact is futile. Nothing can be gained by further perseveration in asking why clinicians fail to adopt research recommendations. Progress may come from asking, instead, why research is failing to provide useful answers to questions important to clinicians. Although there are many potential reasons for this failure, 2 have received little attention: the “messiness” of clinical work and the malign influence of Taylorism. When confronted with an unruly, complex domain, researchers naturally tend to simplify their problems by bounding out the messy details; this approach is efficient but also risks producing keyhole views of clinical work that, for all their internal validity, lack a practical validity as representations of the clinicians’ world.10Nemeth C.P. Cook R.I. Woods D.D. The messy details: insights from the study of technical work in health care.IEEE Trans Syst Man Cybernetics A. 2004; 34: 689-692Crossref Scopus (74) Google Scholar When the messy details that have been excluded are important in making things actually work, then the research leads to irrelevancies. For example, Boyd et al11Boyd C.M. Darer J. Boult C. et al.Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.JAMA. 2005; 294: 716-724Crossref PubMed Scopus (1821) Google Scholar reviewed evidence-based guidelines for the 15 most common chronic diseases, published by national and international medical organizations, and found that, for an elderly woman with 5 common conditions (chronic pulmonary disease, type 2 diabetes, hypertension, osteoporosis, and osteoarthritis), applying all the evidence-based guidelines would require her to receive 12 drugs (costing about $5,000 per year) and a complicated nonpharmacologic regimen, simultaneously exposing her to more than 20 drug-drug, drug-disease, and drug-diet interactions. By bounding out the messiness of the clinical world (in this case, the reality of patients with multiple comorbid conditions), the guidelines have become useless, if not ludicrous. The ironic contradiction between the 2 articles published in this issue may have originated from this bounding-out process. Hurley et al6Hurley K. Sargeant J. Duffy J. et al.Why are emergency departments holding back on holding chambers for children with asthma? facilitators and barriers to change.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar advocating increased use of metered-dose inhalers with spacers (a common academic position, although the evidence supporting it may not be as strong as the advocacy suggests), whereas the elaborate superstructure for moving evidence into practice reported by Wright et al7Wright S.W. Trott A. Lindsell C. et al.Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report.Ann Emerg Med. 2008; 51: 80-86Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar resulted in … a decrease in the use of metered-dose inhalers. The reasons for this unexpected result are not clear but likely lie in the messy details of clinical work that were brushed away in producing the master plan for rational asthma care. “Taylorism” is a highly rationalized approach to management espoused in manufacturing settings by Frederick Winslow Taylor around the turn of the century.12Kanigel R. The One Best Way: Frederick Winslow Taylor and the Enigma of Efficiency. Penguin Books, New York, NY1997Google Scholar Modestly called “scientific management,” it had many characteristics in common with today’s efforts to improve the quality, efficiency, and evidentiary basis of medical practice: a hubristic, muscular belief in scientific modernism; the separation of planning (done by an elite group) from execution (done by ordinary workers); a valuing of abstract, theoretical models (“the one best way”) over informal, front-line experience; and the use of organizational and social authority to enforce these views. Because health care is roughly 100 years behind manufacturing in the process of industrialization,13Kleinke J.D. The industrialization of health care.JAMA. 1997; 278: 1456-1457Crossref PubMed Scopus (12) Google Scholar the appearance of Taylorism in the clinical world is just about on time. In health care, the manifestations of Taylorism include, among other things, the evidence-based medicine and practice guidelines movements. Together they show the separate planning of work (eg, protocols, guidelines) by an academic elite; the desire to “… obtain complete compliance with standardized care, exceptional circumstances notwithstanding”7Wright S.W. Trott A. Lindsell C. et al.Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report.Ann Emerg Med. 2008; 51: 80-86Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar; and the enforcement of those plans from within (eg, physician-specific report cards7Wright S.W. Trott A. Lindsell C. et al.Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report.Ann Emerg Med. 2008; 51: 80-86Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar) or without (“pay for performance” and similar schemes14Rosenthal M.B. Dudley R.A. Pay-for-performance: will the latest payment trend improve care?.JAMA. 2007; 297: 740-744Crossref PubMed Scopus (241) Google Scholar). Taylorism meshes nicely with the scientific positivism that underlies most medical research, but their combined effect is to lead both research and management into programs that are highly rationalized and abstracted, internally consistent, but potentially uninformed by an external reality; hence, the need to translate them. Taylorism ultimately failed in manufacturing, although strong influences are still present in our economic and business systems.15Scott J.C. Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed. Yale University Press, New Haven, CT1998Google Scholar, 16Braverman H. Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century.25th ed. Monthly Review Press, New York, NY1998Google Scholar Thus, we might expect medical Taylorism to similarly founder or be subverted because the models of clinical work inscribed in these systems clash too strongly with the realities of the clinical workplace.17Berg M. Health Information Management: Integrating Information Technology in Health Care Work. Routledge, London, England2004Google Scholar Therefore, we should not expect the applications stemming from these efforts to result in the ideal, rational pathways they were proposed to be, requiring clinicians only to feed in data and occasionally fill in some details. Someone will still have to do the ad hoc, variegated work of managing patients’ trajectories. This is not a deplorable outcome of “corrupting” processes or clinical resistance; it is the only way to get them to work in the first place.18Berg M. Rationalizing Medical Work. MIT Press, Cambridge, MA1997Google Scholar Finding One's Way In Translating Evidence Into PracticeAnnals of Emergency MedicineVol. 51Issue 6PreviewWe thank Dr. Wears for his interest in the emerging scientific discipline of knowledge translation.1 We too recognize that an important divide frequently exists between the findings of robust and valid clinical research and that which actually gets consistently incorporated into clinical emergency medical practice. However, as academics committed to improvements in the uptake of relevant research evidence, we differ in our view of the potential value of knowledge translation in achieving closure of that gap. Full-Text PDF Lost in Translation or Just Lost?Annals of Emergency MedicineVol. 52Issue 5PreviewIn his recent pediatrics editorial,”Lost in Translation,”1 Robert Wears responds to 2 articles addressing the challenges of incorporating new evidence into clinical practice2,3 and criticizes the recent research emphasis upon “knowledge translation.” As the authors of one of these articles,2 we wish to respond to his critique and use it as an opportunity to increase understanding and continue dialogue about the role of knowledge translation. Full-Text PDF Making Change in the Emergency DepartmentAnnals of Emergency MedicineVol. 51Issue 6PreviewKudos to Robert L. Wears for “Lost in Translation,” his editorial commenting on why emergency clinicians are “resistant” to adopting many of the practice recommendations suggested by “evidence” and “guidelines.” It's high time that somebody pointed out that the emperor has no clothes. Full-Text PDF