1,722,357 research outputs found
Why surgeons don’t follow guidelines
No full textIntroduction Widespread and persistent medical and surgical practice variation is held to be a consequence of the failure of clinicians to incorporate research evidence in their everyday work. Practice guidelines are one of the key tactics advocated by the proponents of evidence-based medicine (EBM) to ensure that clinicians apply research evidence to their practice. The critics of EBM contend that there are fundamental differences between the formulised rules encapsulated in guidelines and the type of knowledge required to practise medicine. Much of the opposition to guidelines has been rooted in philosophical arguments about the tensions between "art" and "science", and surgeons, in particular have been quick to argue that the exercise of clinical judgement makes the use of guidelines problematic. The aim of this paper is to suggest why surgeons ignore guidelines. Methods A qualitative study of 34 surgeons practising urology, gynaecology or pelvic surgery in the UK and USA, involved in treating women with stress urinary incontinence. Qualitative interviews and observational methods were used to explore surgeons' views of surgical practice, to examine the nature of everyday surgical work and consider the applicability of guidelines to this area of medical work. Analysis used techniques of constant comparison to generate themes and categories. Results Surgeons view surgical work as contingent: they describe it as both dependent on conditional factors and subject to chance. They respond to contingency by drawing on tacit knowledge and instinctive responses. Surgical judgement provides a strong justification for resisting the imposition of guidelines. Conclusion The technical knowledge embodied in guidelines may be difficult to reconcile with the individual and practical nature of everyday surgical work
Conducting ethnography in medical settings
No full textBackground:
Ethnographic research methods have a considerable history of use in medical settings. This paper provides a personal account of conducting ethnography in medical environments and focuses on some of the practical and ethical issues encountered in such settings.Discussion and Conclusion:
The paper describes particular issues that arise when undertaking ethnographic work, such as gaining access, recording data, research roles and researching elite groups, and recounts some of the dilemmas posed by doing this type of research in a medical setting. The paper concludes by reflecting on what ethnography might offer to medicine in return for the rich data medicine provides
Contingency in everyday surgical work
No full textThis paper concerns a qualitative study exploring the nature of surgical work with a group of 34 surgeons involved in treating urinary incontinence. Sources of surgical variation are identified from surgeons' own accounts of their work as well as observation of the selection of patients and operative procedures, and the operative process itself. A typology of contingency, consisting of three categories of contingency (case, surgeon and external), was found in this area of everyday surgical work. In developing this typology, theoretical and philosophical ideas about habitus and disposition, and practical and technical knowledge, are considered and extended to help to understand the nature of surgical practice. These ideas may also be useful in explaining some of the apparent tensions between evidence-based surgery and everyday surgical work
Communication between anesthesiologists, patients and the anesthesia team: A descriptive study of induction and emergence
No full textPurpose: Although the importance of communication skills in anesthetic practice is increasingly recognized, formal communication skills training has hitherto dealt only with limited aspects of this professional activity. We aimed to document and analyze the informally-learned communication that takes place between anesthesia personnel and patients at induction of and emergence from general anesthesia. Methods: We adopted an ethnographic approach based principally on observation of anesthesia personnel at work in the operating theatres with subsequent analysis of observation transcripts. Results: We noted three main styles of communication on induction, commonly combined in a single induction. In order of frequency, these were: (1) descriptive, where the anesthesiologists explained to the patient what he/she might expect to feel; (2) functional, which seemed designed to help anesthesiologists maintain physiological stability or assess the changing depth of anesthesia and (3) evocative, which referred to images or metaphors. Although the talk we have described is nominally directed at the patient, it also signifies to other members of the anesthetic team how induction is progressing. The team may also contribute to the communication behaviour depending on the context. Communication on emergence usually focused on establishing that the patient was awake. Conclusion: Communication at induction and emergence tends to fall into specific patterns with different emphases but similar functions. This communication work is shared across the anesthetic team. Further work could usefully explore the relationship between communication styles and team performance or indicators of patient safety or well-being
Safe asleep? Human-machine relations in medical practice
Full text linkIn the process of anaesthesia the patient must surrender vital functions to the care of clinicians and machines who will act for, and advocate for the patient during the surgical procedure. In this paper, we discuss the practices and knowledge sources that underpin safety in a risky field in which many boundaries are crossed and dissolved. Anaesthetic practice is at the frontier not only of conscious/unconsciousness but is also at the human/machine frontier, where a range of technologies acts as both delegates and intermediaries between patient and practitioner. We are concerned with how practitioners accommodate and manage these shifting boundaries and what kinds of knowledge sources the ‘expert’ must employ to make decisions. Such sources include clinical, social and electronic which in their various forms demonstrate the hybrid and collective nature of anaesthetised patients. In managing this collective, the expert is one who is able to judge where the boundary lies between what is routine and what is critical in practice, while the junior must judge the personal limits of expertise in practice. In exploring the working of anaesthetic hybrids, we argue that recognising the changing distribution of agency between humans and machines itself illustrates important features of human authorship and expertise
- …
