reductionism revisited

Reductionism revisited

Reductionism:

•understanding the nature of complex things

by reducing them to simpler or more

fundamental things

•a philosophical position that a complex

system is only the sum of its parts

http://www.medical-answers.org/hd/index.php?t=Reductionist

http://www.medical-answers.org/hd/index.php?t=Reductionist

“The night before I got married I tried to make a rational

analysis, reasons for and reasons against......

....but it was a stupid exercise, because no equation of reasons

could even begin to describe the situation.

How is love to be reduced to a series of propositions?

In truth, what binds people together – as a couple or as a

society – always exceeds the reach of a purely rational

analysis.”

Giles Fraser, Guardian, 30 April 2011

“capitalism ... wishes to pursue the maximum

returns on its investment.

To that end it exerts great pressure to turn human beings and nature into commodities.”

The Observer, 24.4.11 http://gu.com/p/2zjbg

http://gu.com/p/2zjbg

Reductionist developments have impoverished the mental health services.

Providing high quality care is reduced to meeting targets;

professionalism is reduced to competences;diagnostic assessment is reduced to assessing needs

and risk;

clinician-patient relationships are reduced to an assembly line model where functional teams provide ‘client-centred’ but fragmented and impersonal care.

The current emphasis on health rather than illness, ... ‘recovery’ rather than

treatments represents ‘magical thinking’ in attempts to deny the existence of

‘madness’ [chronic pain].

These manoeuvres also help to tidy away the suffering and emotional pain of the

mentally ill person [chronic pain patient].

St John-Smith et al, RCPsych 2009

LEAN, NICE, EBM, RCTs and research methodologies

There is a good deal of criticism of evidence based medicine, which is suspected of being a tool not so much for medical science as for health managers

Its main appeal is to health economists, policymakers and managers, to whom it appears useful for measuring performance and rationing resources.

http://en.wikipedia.org/wiki/Evidence-based_medicine

http://en.wikipedia.org/wiki/Evidence-based_medicine

Lean is medicine for healthcare(no patients mentioned)

Healthcare is full of committed, highly trained and motivated staff who struggle daily to work with broken, wasteful and disconnected

systems and processes.

Lean techniques have many of the solutions to sort out, repair and align these processes to organisational objectives.

The solutions themselves come from within the teams working in the systems and processes.

http://www.leanhealthcareacademy.co.uk/how_can_it_help

http://www.leanhealthcareacademy.co.uk/how_can_it_help


Instead of changing it, Lean unfortunately reinforced management in its current paradigm.

As such it represents the further industrialisation of service, with effects that can only be deleterious.

http://www.systemsthinking.co.uk/6-How-lean-became-mean-final.pdf



focus on relationships in service organisations delivers levels of performance improvement that most people wouldn’t dare dream of –

something far beyond the capacity of any commercial toolkit to deliver, even one that calls itself ‘lean’.

(Professor John Seddon)http://www.systemsthinking.co.uk/6-How-lean-became-mean-final.pdf



NICE works with experts ... as well as patients and carers.

We make independent decisions in an open, transparent way,

based on the best available evidence and including input from experts and interested parties.

(how is it obtained?)


NHS Evidence ... provides everyone ...access to a wealth of quality information and best practice

so that every care decision made can be based on the best possible evidence.

(how is it obtained?)

http://www.nice.org.uk/aboutnice/

http://www.nice.org.uk/aboutnice/


The first step of EBM:

translation of uncertainty to an answerable

question

the question should be phrased to facilitate

searching for a precise answer.

http://www.cebm.net/index.aspx?o=1914

http://www.cebm.net/index.aspx?o=1914


EBM ‘not always RCT’

But ‘ecological’ studies ranked 2c in hierarchy

of evidence

Quantitative research is generally made

using scientific methods, which can include:

developing instruments /methods for

measurement.

control and manipulation of variables.

collection, modelling and analysis of empirical data.

The null hypothesis, H0, is an essential part of any research design, and is

always tested, even indirectly. http://www.experiment-resources.com/null-hypothesis.html#ixzz1LNCWawK0

http://www.experiment-resources.com/null-hypothesis.html#ixzz1LNCWawK0

Alternative terms for the traditional research paradigm are:

quantitative, scientific, experimental, hard, reductionist, prescriptive,

psychometric

http://www.postgrad_resources.btinternet.co.uk/student-resources11qual-quant.htm



The traditional research paradigm relies on

numerical (i.e. quantitative) data and

mathematical or statistical treatment of

that data.

The 'truth' that is uncovered is thus

grounded in mathematical logic. http://www.postgrad_resources.btinternet.co.uk/student-resources11qual-quant.htm


most of us are happy to accept uncritically simplified, reductionist, and blatantly

incorrect statements so long as they contain at least one number

Greenhalgh, BMJ 1997

Qualitative research:

aims to gather an in-depth understanding of human behaviour and the reasons that

govern such behaviour.

In qualitative research the possibility of the researcher taking a 'neutral' position is

seen as more problematic.

Qualitative researchers are exhorted to reflect on their role in the research process

and make this clear in the analysis.

a reductionist approach isolates variables and

establishes relationships between them,

qualitative methods

examine how variables interact to become systems

which cannot be completely understood from

looking only at the sum of the parts.

There is ample evidence that the legitimacy and usefulness of qualitative research is no

longer questioned by most prominent scholars in administrative and organization

science. (January 2011)

http://gsbapps.stanford.edu/researchpapers/library/RP2045R.pdf

http://gsbapps.stanford.edu/researchpapers/library/RP2045R.pdf

Fig 1 Percentage of research in BMJ that is qualitative, 1994 to 3 September 2010.

Paley J , Lilford R BMJ 2011;342:bmj.d424

©2011 by British Medical Journal Publishing Group

No mention of qualitative research methods

Researchers who use qualitative methods seek a

deeper truth.

They attempt to make sense of, or interpret,

phenomena in terms of the meanings people bring

to them,

adopting “a holistic perspective which preserves

the complexities of human behaviour.”

Greenhalgh, BMJ 1997

Qualitative researchers aim to gather an in-depth

understanding of human behaviour and the reasons

that govern human behaviour.

Various aspects of behaviour could be based on

deeply held values, personal perspectives,

experiences and contextual circumstances.

http://www.hopkinsmedicine.org/gim/research/method/qual.html

http://www.hopkinsmedicine.org/gim/research/method/qual.html

Here are a few important research questions in

emergency medicine-

Should we allow relatives to witness resuscitation?

Are patients reassured by negative tests?

What makes working in emergency medicine stressful?

Are patients satisfied with the emergency care they

receive?

What is the effect of consultant shop-floor presence?

These questions cannot be answered very

satisfactorily by our familiar quantitative

methods (counting and measuring). They

require a deeper understanding of attitudes,

experience and behaviour. We therefore need to

use a different research methodology -

QUALITATIVE RESEARCH.http://www.collemergencymed.ac.uk/CEM/Research/technical_guide/qual.htm

http://www.collemergencymed.ac.uk/CEM/Research/technical_guide/qual.htm

Positivism and Reductionism

Positivism: "the view that all true knowledge is scientific, and that

all things are ultimately measurable.

"entities of one kind... are reducible to entities of another,”

"processes are reducible to physiological, physical or chemical events,“

"social processes are reducible to relationships between and actions of individuals,“

Is there a philosophical difference between

quantitative and qualitative research?

Positivism Constructivism

Single tangible reality, fragmented into variables

Multiple constructed realities

The inquirer and the object of inquiry are independent.

Knower and known are inseparable.

Every action can be explained as the result of a cause.

Cause and effect are interlinked.

Inquiry is value free. Inquiry is value bound.

Inquiry is experimental and quantitative.

Inquiry is mainly qualitative and interpretive.

It is impossible, without further inquiry, to rely on what people say about themselves, their experience, or their interpretations of

what has happened to them.

Paley & Lilford, BMJ, 342: 30 April 2011

the assumption being that there is a single verifiable truth

Understanding the context in which people

live is essential.

Qualitative researchers need to identify their

own contexts so that they understand how

their own views and beliefs may influence the

interactions they have with their participants.

Kuper, Reeves & Levinson, BMJ 2008; 337:a288

People understand the world differently, this

informs their beliefs, attitudes, intentions and

actions.

Understanding these differences is sometimes a

matter of listening rather than counting.

Which is why history-taking is still important.

http://www.bmj.com/content/342/bmj.d424.full/reply#bmj_el_250051


positivists may argue that "if you can't measure

it it's not worth studying";

their own problem is that if you can measure it,

it's inevitably simplified and is therefore

probably not "it".



Conventional investigations do not reveal the cause of pain -

diagnostic joint blocks and CT discography can provide a diagnosis:

15- 40% of patients have zygapophysial joint pain, 20% have sacroiliac joint pain

>40% have internal disc disruption

Management of chronic low back painNikolai Bogduk

MJA 2004; 180 (2): 79-83

Reductionism in chronic pain – alive and kicking

Fitness to work – a reductionist paradigm?

Many clients with serious health conditions have been found fit for work, including those

with multiple sclerosis, terminal cancer, bipolar disorder, severe depression, and

agoraphobia.

BMJ 2011; 342

The comfort of reductionism

Certainty offers security

The illusion of “absolute truth”

The illusion that the right doctor will find the right

answer (and thus a cure)

One day we will know ‘it’ all and have all the answers.

Divide each difficulty into as many parts as is feasible and necessary to resolve it.

Rene Descartes

The whole is more than the sum of its parts.

Aristotle

the love of complexity without reductionism makes art

the love of complexity with reductionism makes science

Edward O Wilson