It’s 20 years since the British Medical Journal (BMJ) sent me a paper to review with the made-up word ‘mindlines’ in its title.1 The covering email said something like ‘we’ve already decided to reject this paper but could you please quickly skim it and give us some reasons to pass on to the authors?’ I was intrigued. Even the BMJ didn’t usually reject qualitative research submitted by well-known professors without reading beyond the title. I read the paper and told the editor he should publish it as soon as possible because it described the most philosophically important research study he’d ever sent me. A few years later, a different BMJ editor ranked that paper (which has now been cited over 1200 times) among the BMJ ’s top 20 in the 20 years since the journal went digital,2 and in a subsequent BMJ poll it was voted the top research paper.
The paper described an ethnographic study of a highly-rated, well-renowned primary- care practice. Two researchers — a doctor and a nurse, respectively, by training, both with an anthropological bent — sat in GPs’ surgeries and nurses’ clinics and watched the clinicians to see how they practised so effectively. And what they watched was good clinicians not following guidelines. Actually, the GPs and other clinicians did use guidelines — just not in the way the evidence-based medicine playbook assumed (consulting a formal written or online guideline in real time when seeing a patient, for example). So how do clinicians follow guidelines? Let me quote from page 20 of Gabbay and le May’s new book:
‘Practitioners rely on a wide variety of sources and types of evidence that they must meld together to help them deal with the situations they face. Rather than relying simply on science-based guidelines or other formal, theoretical knowledge, practitioners deploy their knowledge-in-practice- in-context. They rely on their mindlines — flexible, malleable, rapidly accessible, internalised, collectively reinforced, and often tacit guidelines-in- the- head — that they accumulate throughout their careers. […] The development of collective mindlines is a form of social construction of knowledge, highly dependent on the social relations that shape people’s understanding of illness and disease.’
According to this model, the guidelines that matter are not the voluminous ‘if X, do Y’ instructions produced by the National Institute for Health and Care Excellence or the tortuous algorithms embedded into decision support software — or at least not those sources in isolation. Rather, the things that guide us are the things we know because — to the extent that we are experienced and wise and connected with others in our field — they’re in our bones, our jokes, and the unwritten rules that drive our collective ways of thinking and working. We are, individually and collectively, guided by a form of remarkably fast thinking that is long and hard won, and which enables us to care effectively for those patients — often the majority — who are ‘exceptions’ to the one- size-fits-all evidence-based guideline, and by the stories we share in the spaces in between our patient encounters.
MINDLINES AREN’T JUST INTERNALISED INSTRUCTIONS FOR WHAT TO DO
By the time Gabbay and le May’s research revealed this finding (which is startling and reassuring in equal measure), the word ‘guideline’ had already been taken, so they coined a new word: mindlines. Mindlines are not just internalised instructions for what to do. Mindlines are what we share, including the facts we know and the issues we care about. Because of their link to our professional identity, mindlines are also who we are. We collectively get our heads round a new cardiovascular guideline and acknowledge formal thresholds for up-titrating antihypertensive or heart failure medication. But we also collectively understand the reasons for sparing our nonagenarian patients the tyranny of polypharmacy and the medicalisation of their twilight years. We engage with guidelines not as automatons but as communities of professionals.
That much was set out in Gabbay and le May’s first book in 2011.3 In 2015, Sietse Wieringa and I reviewed the many studies that were based on this rich and intriguing view of clinical knowledge.4 Mindlines, it seemed, were everywhere, and explained much of the gap between the evidence-based ideal and the practical realities of clinical practice.
WHAT DOES THIS LATEST COLLECTION ADD?
Mostly, it adds a wealth of detailed examples written by others. Here are some of the highlights. Shout out to my ex-PhD student, dentist Dominic Hurst, who used video ethnography to explore the multiple kinds of knowledge — including the embodied understanding of what enamel and soft tissue feel like through the end of a drill — that are subtly brought into play when your dentist fixes your tooth.
Nurse researcher Kate Beckett and theatre director Tony McBride used forum theatre to create discussions about the complexities and contradictions of people’s psychological recovery from major trauma. Theirs were not simple stories with unequivocal happy endings. The dramaturgical form allowed multiple knowledges to be surfaced, enacted, and combined, which they then invited audiences to reflect on and so change how they practice.
In a ‘situation report from New York City’, emergency medicine physicians Edward Suh and Peter C Wyer give a gripping account of how mindlines informed their response to the first wave of the COVID-19 pandemic. At a time of unprecedented pressure on services, a near absence of formal guidelines, wretched human suffering, and moral injury among staff, clinicians drew on a multitude of sources including clinical experience, storytelling, social media interactions, and rapidly published research preprints to build and apply dynamic knowledge at the clinical frontline.
Another PhD, by Michael Hodgins, supervised by Ann Dadich and Jane Bye, looked at the role of emotions in the delivery of community-based palliative care. These authors show us how emotions are not separate from our knowledge but part of that knowledge. As one palliative care nurse quoted in their chapter said (on page 78), ‘you cannot do your job without emotions’. They reach the intriguing conclusion that in palliative care, ‘Mindlines were assembled with emotion as a productive mechanism to prioritise or limit certain kinds of care’ (my emphasis).
Who should buy this book and why? First and foremost, people who want a beautifully written antidote to the reductive depiction of clinical practice as rational, algorithm-based decision science. Second, those who study and teach clinical knowledge — especially ye who believe, naïvely, that evidence- based medicine will serve up most or all of the answers. And, finally, the philosophers among you, who will find, in among the rich accounts of how mindlines have informed and explained effective interventions in a wide range of clinical settings, conceptual and theoretical gems from (among others) Wittgenstein, Polanyi, Heidegger, Dewey, Marx, Schatzki, Garfinkel, and Tsoukas.
Footnotes
This review was first posted on BJGP Life on 20 May 2023; https://bjgplife.com/mindlines
- © British Journal of General Practice 2023