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How is knowledge mobilized when we can’t agree on what knowledge is? Reconciling “practice relevance” and “the public interest” across boundaries of research-practice & medicine- social science

Peter Nugus

Australian Institute of Health Innovation, Macquarie University 6th April, 2019

Peter Nugus, Maud Mazaniello-Chezol, Nadjib Mokraoui, Anna Horton, Josianne Lamothe, Gillian Bartlett, Emille Boillot, Paula Bush, Annabelle Levesque-Chouinard, Jamieson Clark, Valérie Dory, Marion Dove, Roland Grad, Matthew Hacker Teper, Vania Jimenez, Audrey Juras, Kendall Kolne, Neb Kovacina, Lucie Lambert, Serge Medetongnon, Pierre Pluye, Ellen Rosenberg, Leora Simon, Myriam St-Pierre, Isabelle Vedel, Laura Rojas-Rozo, Jeannie Haggerty

Co-investigators

Outline

• Knowledge mobilization across boundaries
• Methodology: multiple case study and mixed methods
• Case 1: Medical student ethnographic project
• Case 2: Promoting practitioner-led research (PBRN)
• Case 3: Designing a new PhD in Health Sciences Education
• Discussion / conclusion: Reconciling cultural differences

across knowledge boundaries

Knowledge mobilization across boundaries

• Movement towards greater research engagement by

practitioners (Borkowski, 2016; Harding, et al. 2017; Kuyare et al., 2016)

• Evolving relationship between knowledge use and

production

• Neo-liberalism: It’s good for “the people” is research is

“practical” (Giroux, 2007, 2008)

• Despite the complexity / specialization of modern

societies.

• Generalized calls for accessible knowledge to benefit users

(“democratizing”) (Alison et al., 2017; Heard 2017; Matus et al., 2018)

Knowledge mobilization across boundaries

• Less research on how characteristics of different knowledge

communities influence knowledge mobilization efforts

(Borkowski 2016; Harvey, et al., 2016; Hanlon et al., 2018; Matus et al., 2018)

• In order to inform / effect structural changes, we need

clarity over the cultural differences between different stakeholders/communities Objective: To understand the influence and implications of power differences, priorities, cultures and perspectives among different knowledge communities for sustainable knowledge mobilization.

Methodology

• Multiple qualitative case study:
• Case 1: Medical student ethnographic project
• Case 2: Promoting practitioner-led research (PBRN)
• Case 3: Designing a new PhD in Health Sciences

Education

Methodology

• Mixed methods (within a qualitative framework):
• Semi-structured interviews for three cases
• Field interviews for three cases
• Field / journal notes for three cases
• Document analysis for two cases
• Observations for one case
• Pre-post surveys for one case

Methodology

• Data analysis:
• Qualitative content analysis for three cases
• Exploratory factor analysis & repeated measures ANOVA

for one case

• Human research ethics:
• Secured separately for the three cases

Case 1: Medical students’ mandatory ethnographic project

• Context:
• 2015-2018 – In new curriculum
• Mandatory, 2nd year (Jan-June), 180 students per year
• Only such mandatory course anywhere

Case 1: Medical students’ mandatory ethnographic project

• Context:
• Activity: An activity (Observing Healthcare in Action - OHA) in

which students combine direct / “live” observations of clinical care with broad understandings of the meaning of that care – through focus on a particular theme (e.g. patient safety, interprofessional relations etc.):

• 2 lectures (including Socrative) & 2 workshops
• Supporting documents (e.g. Guide) and articles
• 3 x 3 hour observations in a primary care clinic
• Analysis in written assignment / oral presentation
• Wine & cheese with clinical sites & the 4 best presentations

Case 1: Medical students’ mandatory ethnographic project

• Organizational context:
• In Transition to Clinical Practice
• Housed in Department of Family Medicine (DFM)
• McGill accepts undergraduate medical students
• Insufficient family medicine residents
• In Accreditation, faculty had performed poorly in student

responsiveness, and received negative publicity

• “Medical dominance” or the medicalization of society is

grounded in medicine’s unique (“esoteric”) knowledge and language (Abbott, 1988; Freidson, 1970; Willis, 1989)

• Writing / reflective activities tend to play down evidence.

Case 1: Medical students’ mandatory ethnographic project

• Objective: For students to understand that medical

decisions (such as about diagnosis and treatment) are influenced by contextual factors and perspectives on clinical care (beyond bio-medicine) (e.g. technology, inter-professional relations, staffing levels etc.)

Assignment / presentation topics

Interactions/Communication (15%) Space/waiting room (13%) Inter-profession relations/roles (12%) Organizational/work culture/processes (11%) Technology (9%) Patient culture/needs (8%) Reception (7%) Policy-practice (7%) Professionalism/ethics (6%) Governance/structure (4%) Infection control (3%) External relations (3%) Other (2%)

• Findings:
• The students learned:

Case 1: Medical students’ mandatory ethnographic project

• 490 pre-post surveys by 197 students (2015-2017)
• Significant increase (p<0.02) for the perceptions of

understanding how healthcare is organized.

• How health organizations work
• The role of primary care clinics in the

health system

• The structure of health care in this

province

• The structure of primary health care in

this province

• The roles of health care staff in roles
• ther than medicine

“I understand…”

• (R)evolution:
• Name – from ethnography to OHA
• Aims – from ethnography to institutions/organizations
• Activity / Delivery methods – fewer workshops, shorter

lectures, from 3 to 2 observations

• Assessment requirements – from written to oral
• Variable support – a strong “determinant”
• Negotiation – continual and intense / needed insider/s

Case 1: Medical students’ mandatory ethnographic project

Case 1: Medical students’ mandatory ethnographic project

Student perspectives, behaviours and outcomes:

• Questionable relevance to “real medicine”
• “Real” (foundational) medicine first
• Organized resistance (lobbying, student representatives)
• Students perceive that they already do a lot of writing
• Ultimately succeeded in having the exercise removed.

Case 1: Medical students’ mandatory ethnographic project

"In particular, my observations of the interprofessional team, with an emphasis on the role of the nurse and of the psychotherapists, as well as my discussions with these professionals, have made me realize that even though the work that a physician does is crucial, there are several essential aspects of patient care that the allied health professionals are much more qualified to address. Going forward in clerkship and beyond, this realization will likely encourage me to give much more weight to their point of view when establishing a plan for the care of my patient, and to try and consider things from their point of view.”

(OHA student, 2017)

Case 1: Medical students’ mandatory ethnographic project

"Up until now, we have received a universally optimistic view of

• medicine. This course was one of the first opportunities where

we were invited to think critically about the care patients receive and to make recommendations to improve care. I believe the constant positive framing of medicine is problematic because it becomes harder for us to receive criticism from our patients or our colleagues since we believe there’s nothing wrong with the way medicine is practiced."

(OHA student, 2016)

Case 1: Medical students’ mandatory ethnographic project

“… It would be nice to have time to just focus on studying medicine and not having to do projects that are unrelated”.

(Medical student)

“There are many other more pressing issues to deal with at the point we are at in our career, and this seems like a waste of

• time. … (It’s) not very relevant for us.”

(Medical student)

Case 1: Medical students’ mandatory ethnographic project

• Social science lecturer / coordinator perspectives, behaviours &
• utcomes:
• Extensive consultation (8 physician-social scientists in 4 countries,

15 students past and present, TLS etc) and amendments

• Intense lobbying
• Strong response to internal review
• Considerable learning by students
• Exceptionally high quality of written assignments
• Unsuccessful in retaining the exercise in TCP, but given opportunity

to re-approach Undergraduate Curriculum Committee with an alternative proposal.

Case 1: Medical students’ mandatory ethnographic project

• Structure of lecture 1:
• 1. Socrative exercise
• 2. Youtube intro to ethnography: The Hidden Obvious
• 3. 2 cases: Hoarding and hand-washing
• 4. What are the objectives?
• 5. Why do I need to do this exercise?
• 6. How will I do it?

Case 1: Medical students’ mandatory ethnographic project

• Structure of Lecture 1 (Part 5):
• Why understand health care contexts?

1. Medicine is not a meeting of 2 biological entities. 2. Care needs to be different under different circumstances. 3. The power differences between doctors and patients has roots in bio-sciences, and political, economic and social history. 4. Poverty makes you sick. 5. Doctors work as parts of complex systems, not as unimpeded agents. 6. Medicine is scientifically uncertain.

Case 1: Medical students’ mandatory ethnographic project

• Report on TCP-OHA (14-page, aligning with Faculty Vision &

Mission document, and Accreditation Standards, and including detailed response to Internal Review):

“… In essence, the following points are elaborated in this report: 1. The OHA fills a previously unmet curricular need regarding social accountability and patient advocacy in the …. medicine curriculum. 2. There are objective, independent and under-recognized indicators that the learning from this activity is highly valuable for students, and hence, ultimately, for patients and citizens of Quebec and Canada.

Case 1: Medical students’ mandatory ethnographic project

• 3. Although medical students are not socialized to value – and are able

to strongly resist – knowledge and skills on the organization and context of health care, such knowledge and skills are needed by the Quebec and Canadian people, who pay for medical education and health care.

• 4. The OHA exercise should remain in the curriculum as a

mandatory exercise. …” (Executive Summary, “OHA’s Redress of the Unmet Curricular Need for Social Accountability and Health Advocacy: Don’t Throw the Baby out with the Bath Water!”)

Case 1: Medical students’ mandatory ethnographic project

• Faculty perspectives, behaviours & outcomes :
• Strongly supportive of student opinion, especially following

Accreditation incentives

• Appeared to value student perceptions over “independent/objective”

indicators of learning

• Relatively patient
• There was some challenge to the Department of Family Medicine’s

perspective

• Denied it being a question of “liking” or “not liking” the component
• The component was removed

Case 1: Medical students’ mandatory ethnographic project

Summary: Differences between social scientists and medical students reflected greater legitimacy of bio-medicine over social science.

Case 1: Medical students’ mandatory ethnographic project

• “It’s not because they don’t like it!” (Faculty representative)
• “You didn’t sell it to them.” (Faculty representative)

Case 2: Promoting practitioner-led research

• Context and background:
• Primary care Practice-based Research Network (PBRN)
• 10 primary care sites (urban, regional and rural) in a

university network

• Attempt to re-orient towards primary care
• Part of larger PBRN networks in QC (Réseau-1), Canada

and worldwide

Case 2: Promoting practitioner-led research

• Context and background:
• New law for GPs to have 300 more patients each
• Accreditation requirement to do academic activity:

changed from “research project” to “scholarly activity” to “QI project”

• Acting Director encouraged to re-name it the “Practice-

based Learning Network” (PBLN)

• There is ambiguity over research versus QI for research

ethics purposes, and research ethics versus clinical ethics.

Case 2: Promoting practitioner-led research

• Context and background:
• Local activities:
• Attempt to have an online platform for project

monitoring and linking research needs and interests, “clean up” ethics approval processes, day-long symposium, resident research day, to be the main research gatekeeper between DFM and clinical sites.

Case 2: Promoting practitioner-led research

• Context and background:
• Aim: promote practitioner-led research in primary care
• Various levels of activity across the 4 Quebec Family

Medicine departments, partly mediated by age, internal support, integration with leader’s research profile

• Some financial support from R-1 and have prizes,

competitions etc.

Case 2: Promoting practitioner-led research

• Context:
• Participatory organizational ethnography:
• Field observations and interviews in six sites (in

progress)

• Interviews with site representatives in various roles,

and directors / coordinators / leaders in in educational, QI, management and methodological support roles

• “Research Readiness” survey with key informants

Case 2: Promoting practitioner-led research

• Findings:
• Research is seen to be distant from practice – even

incompatible.

• Family doctors feel that they lack knowledge, skill and

experience.

• Research is seen to be quantitative, and require multiple sites,

very large participant numbers and be largely bio- medical/lab-based.

• This view increased the perceived gap between research and

practice in Family Medicine.

Case 2: Promoting practitioner-led research

“So I get a bit confused …. Where do you fit in? … Do you know (named a close colleague)? … Because when I hear about all the different, you know, associations and stuff, it’s like: ‘OK, are you guys all under the same roof?’ But it’s different groups, or, different interests, like, because I’ve like seen you guys in the Department of Family Medicine. So, it’s like, how does it all work, you know, because there’s a lot going on? …. I mean you’re at McGill, but there are so many different departments at McGill … ”

(Primary care physician)

Case 2: Promoting practitioner-led research

“There’s a sociologist (in the Department of Family Medicine), and anthropologists? OK. … I had no idea.…”

(Family Medicine physician)

“I have no idea what happens in the castle up there (of the Department of Family Medicine). … And you can imagine, in (named rural site), they’re like: ‘(DFM) is an ivory tower and all they do is talk about research, and going to Brazil and China, and what does that have to do with me and my patients?’ ….”

(Family Medicine physician)

Case 2: Promoting practitioner-led research

“I’d say … ‘Hey, I’ve got people here from the PBRN. They keep hassling me, because they want to talk to me, but I don’t know how to help them. So, I should probably try and find out. I’m also supposed to be a director, so I should probably know what’s going on and direct things, because I have no clue (chuckles). … I feel guilty that I can’t be a better supervisor. … We’d like to get the residents involved (in research) because we recognize that it’s important but we’re held back by fear and lack of experience. … As clinicians, research is something we hold in high esteem … (Clinicians who do it are) our best and our brightest . … We almost feel like we’re not good enough …”

(Primary care physician)

Case 2: Promoting practitioner-led research

“When promoting (practice-improvement projects, my colleague hastens to re-assure them): ‘this is not research’ ”

(Faculty member engaged with improvement projects)

Case 2: Promoting practitioner-led research

“(There’s) so many patients. … We have other responsibilities … and (resident) teaching. …When are we going to get time for this?

(Primary care physician)

“I’ve never really done research. …. I don’t know the stats. We’d need a statistician to support us. … We don’t see the numbers for any one focused study … We’re family doctors. …. We don’t really do research. … We’re too general. The specialties do research. They’re more specialized. … And we don’t see the numbers in any one condition to do proper

• research. …”

(Primary care physician)

Case 2: Promoting practitioner-led research

“… Most family medicine residents have … very little exposure to going through journals and actually sorting through the literature, and getting the right information to be able to properly formulate a research question … we do our QI meetings …. I … feel there’s a huge black box … What’s more, family medicine is so vast. … Part of the job of a specialist is to be a researcher because everyone has their domain of

• expertise. …. I think the distinction between clinician and

scientist is (stronger) in primary care (because it’s so vast) … And I think for that reason a lot of people go: ‘No, I’m not a research person’ … There’s a big divide”.

(Family medicine resident)

Case 2: Promoting practitioner-led research

“… One of my residents said to me: ‘Oh, I was so happy we (the students) got rid of the ethnography course. … But then he said: ‘now I see that it was actually very useful and gave me a different way to see things that’s really relevant to the context

• f family medicine’ … ”.

(Family medicine physician)

Case 2: Promoting practitioner-led research

“Family medicine provides a lot of opportunity, but can be very stifling.

We go through medical school and exposed only to clinical research. …. (As Family Medicine residents) we don’t have as much access to hospital

• resources. ….. We don’t have the opportunity to explore different types of
• research. Observational, behavioural etc …. What’s needed to maximize

the settings, or flow. ….. When we did (the OHA), that was the first time we’d been exposed to methods that could remotely tackle the complexity

• f what family doctors do. … Otherwise, we don’t get taught about that

in medical school …. So we need a methodologist to guide resident projects …. and let us know what sorts of ways we can answer certain questions and what resources and what end points … (such as doing research) in the waiting room. Do we need to publish to have an impact. ….? We’re not exposed to that type of research …. I feel that I’m more excited about non-clinical research ….. (it’s more suited for) primary care. … We’re supported by the tool in deadlines, but (not how to go about it). …”

(Family Medicine resident)

Case 2: Promoting practitioner-led research

Summary: Differences between researchers and MDs reflected a distinction between theory (research) and practice, and greater perceived legitimacy of quantification over qualitative phenomena, and bio-medical (tangible) phenomena over contextual (less tangible) phenomena.

Case 3: Designing a new PhD in Health Sciences Education

• Context:
• Centre for Medical Education became an Institute of Health

Sciences Education in February 2019

• PhD Proposal & Development Committee
• Health Sciences Education research and Health Professions

Education research are growing fields.

• The “field” / these fields developed from a practice domain,

implying a potential tension between theory and practice.

• The field has evolved from being discipline-specific to being

(inter)disciplinary to posing discovery-driven questions.

• There are few such dedicated PhD programs in the world (27)

Case 3: Designing a new PhD in Health Sciences Education

• Background:
• Weekly seminar is the main joint activity (definitional of the identity of the

centre and members, and supportive environment)

• Rationale for Institute was to build a scholarly community, of which a PhD was

a part

• Individual departments / Institutes can decide entry criteria (to a point), who

can supervise PhDs, and the structure of courses and the Comprehensive Examination.

• University discourages too many mandatory courses, and those which overlap

with available courses

• The “capstone” course is decisive in putting the case for the need and
• riginality of the PhD program.

Case 3: Designing a new PhD in Health Sciences Education

• Findings:
• “PhDs” have been pushing “theoretical standards”, and MDs have

been pushing accessibility and proximity to practice:

• PhDs have argued that theoretical strength is

definitional of a PhD, and to compromise would be a betrayal of standards.

• MDs have conveyed concern that the program be

practice-based, for fear of losing or antagonizing current clinicians.

Case 3: Designing a new PhD in Health Sciences Education

• Findings:
• E.g. PhDs supported a Mandatory “Research Design /

Theory / Methodology” course, which MDs were more likely to think should be optional.

• E.g. MDs were more likely to think that the Seminar

course should be mandatory, with the PhDs more likely to want it to be optional, or, if mandatory, theoretically- driven.

Case 3: Designing a new PhD in Health Sciences Education

• Findings:
• Entry standards:
• “Traditionally, physicians have been allowed to enter

a PhD without a Masters degree and with a high GPA. … There’s a reason for that. … They have a strong scientific background … and (many of them) have been involved in research.” (Manager)

Case 3: Designing a new PhD in Health Sciences Education

• Findings:
• Entry standards:

“We need to ensure that students coming in are … appropriately skilled. … They should have done a three-credit course in (each of) qual and quant … or – and this is just my opinion – they should do it in the first two years (of their enrolment in the PhD)” (PhD Researcher)

Case 3: Designing a new PhD in Health Sciences Education

• Findings:

PhD student supervision:

• “I’m really sorry … I know this isn’t going to make me popular, but

I feel very strongly … that … only people with PhDs … should be able to supervise PhDs … as primary or co-supervisor. …”

(PhD Researcher)

• “I’ve been a co-supervisor on a PhD before.” (MD)

Case 3: Designing a new PhD in Health Sciences Education

• Findings:
• 10-page first-level application for a new PhD program:

“… Currently, the cohesive body of knowledge in the field of HSE research manifests not only in the search for solutions to practical problems, but is increasingly characterized by discovery-driven

• science. … The context of HSE research is complex in its interplay of

theory and practice, because much of the subject matter of HSE research arises from challenges in, and is invariably connected to, the applied contexts of health care and health education.

Case 3: Designing a new PhD in Health Sciences Education

• Findings:
• 10-page first-level application for a new PhD program:

“… The authentic environments that give rise to much of HSE research requires education in the way knowledge is produced, used, shared, exchanged and translated in complex, diverse and practice-based

• settings. … The intellectual needs of the cross-professional contexts of

HSE, and the trans-disciplinary understanding required for HSE research, are not met in current graduate research programs in the clinical sciences, or the social sciences, including education”.

(PhD Development Committee, IHSE, New Graduate Program Framework Document, McGill University)

Case 3: Designing a new PhD in Health Sciences Education

Summary: Differences between researchers and MDs manifested as a distinction between theory (research) and practice.

Discussion

• There are differences among the stakeholder communities

that are patterned in terms of, or manifesting as different priorities, perspectives and incentives. ? = unknown or inconclusive ?? = ambiguous / conflicting priorities and incentives

Case PhDs / researchers Social scientists Medical students MDs Faculty/ uni Govern- ment 1 X X ? X ?? 2 X X X ?? 3 X X X ??

Discussion

• The differences centred on distinctions of theory-practice,

quantitative-qualitative, and bio-medicine-social science (material-immaterial).

• Different levels / manifestations of power in those dyads.
• Medicine and quantification have prevailed, but

theory/research versus practice is ambiguous because the

• bject of inquiry is about research itself.

Discussion

• Raises normative versus empirical questions:
• Who has legitimacy vs whose voice should be legitimate in

speaking for “the public interest”?

• Persuasion works at an individual level, but if structural

change is sought, e.g. to redress medical dominance, how knowledge is understood etc., change is needed at individual, institutional and systemic / policy levels.

Discussion

• Medical education should be structured / incentivized to

see medicine as grounded in different bodies of knowledge E.g.

Discussion

• Medical education should be structured / incentivized to

regard learning/education as inter-connected (mutually influential) and inter-subjective, rather than stemming from individual cognition and morality.

• Where behaviour is able to be described by virtue of

structural incentives, rather than “moralized” in terms

• f individual attitudes.

Discussion

• Academics should advocate for, and design policy-relevant

ways to advocate for theory to be understood as connected to practice, by virtue of its specialized role in a complex society.

• Strategies are needed to persuade policy, educational and

professional bodies to promote qualitative research as appropriate for health care delivery improvement:

• on the grounds of its contextual (and, hence practical)

relevance ;

• If we take the view that investigation (e.g. QI) is only

research if it is transferable;

• and only if its transferability is justified in terms of the

association between theory and its purposive sampling.

Discussion

• “Deliberative democracy” might be a conceptual guide /

model for knowledge mobilization:

• Perspective that decisions are made in “the public

interest”, not by quantification, but by publically- motivated deliberation among equals.

• Befits a complex society in that it allows for different,

legitimate interests to be represented even indirectly.

• Engaging with practically-informed theory means that

research can be “practice-relevant” without necessarily being only practice based.

Conclusion

• More engagement needed with patients/citizens, care-

givers, and Allied Health and Nursing professionals.

• Policy / governmental perspective needs more

consideration in terms of how differences between various stakeholder communities, relate to knowledge mobilization, given the ambiguity of policy incentives.

• More exploration is needed on the relationship between

research and QI for the purposes of publication and ethical approvals.

• A clearer distinction is needed between stakeholder groups

and the issue or philosophy that their perspectives represent.

Dr Peter Nugus peter.nugus@mcgill.ca

References

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References

Harding, K., Lynch, L., Porter, J. & Taylor, N. F. (2017). Organizational benefits of a strong research culture in a health service: A systematic review. Australian Health Review, 41, 45-53. Harvey, D. et al. (2016). Becoming a clinician researcher in allied health. Australian Health Review, 40(5), 562-569. Kuyare, M.S., Sarve, P.V., Dalal, K.S. & Tripathi, R.K. (2016) Evaluation of performance of the Medical Research Department in 'Research naive' non- academic hospital: An audit. Perspectives in Clinical Research, 7, 174-80. Matus, J., Walker, A., & Mickan, S. (2018). Research capacity building frameworks for allied health professionals- a systematic review. BMC Health Services Research, 18:716. Willis, E. (1989). Medical Dominance: The Structure of Australian Health Care. Sydney, NSW: Allen & Unwin.

Professor Pierre Pluye, Department of Family Medicine, McGill University