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On the power of poetic praxiology, and seven principles of change in complex systems

Researchers and health reformers have been urged to hone their skills in story-telling and to unlearn scientific teachings that do not value the power of narrative.

In arguing for the merits of detailed case narratives, Professor Trish Greenhalgh provided a case study in “poetic praxiology” during her keynote presentation to the recent Choosing Wisely Australia National Meeting in Melbourne.

Marie McInerney is covering #OKtoAsk2019 for the Croakey Conference News Service.


Marie McInerney writes:

A leading international health academic and practitioner has recommended seven principles for bringing about change in complex systems, and called for less reliance on “gold standards” like randomised controlled trials (RCTs) and more on “the power” of stories and relationships.

Professor Trish Greenhalgh, who is Professor of Primary Health Care Sciences at Oxford University, also urged GPs and others in primary care to join the Choosing Wisely campaign to reduce unnecessary and sometimes harmful tests, treatments and procedures, saying there is “huge potential” for overtreatment and overdiagnosis in primary care.

And she called for the wider health sector to “work actively” with the media to address fake news and unscientific debates in the wake of  developments like Brexit, which she said is now posing major implications for health and health care in the United Kingdom.

An international leader in thinking about complex systems change, Greenhalgh was in Melbourne as keynote speaker at last week’s 2019 Choosing Wisely Australia National Meeting.

She told participants that science and academia have gone “a little bit overboard” on RCTs, long seen as gold standard building blocks for evidence-based medicine, though she admits she is only alive thanks to their efficacy.

“I’m a cancer survivor and I was treated with a package of treatment that had been tested in an RCT, so I’m not opposed to RCTs.”

But she said they “work a lot better when you’re assessing a drug than they do when you’re assessing a complex innovation”.

She said:

Yes, they are a brilliant way, the best way, of eliminating most of the biases, and demonstrating that a is better than b under different conditions.

But if what we want to do is change what we do in the real world, they’re an absolute disaster of a methodology.”

Complex systems

Greenhalgh’s keynote address was about the challenges of spreading and scaling up change in complex systems, a big focus now for the Choosing Wisely movement in Australia as it looks to achieve greater scale and sustainability for the initiatives already undertaken in individual sites and services.

Her address included a detailed look at her ongoing (and as yet unpublished) work with The George Institute for Global Health in Sydney, which is evaluating its TORPEDO (Treatment of Cardiovascular Risk using Electronic Decision Support) that involved the Health Tracker app for GPs.

While it “wasn’t a disaster by any means”, Greenhalgh said there were lessons to be learnt from an initiative that followed so many of the recognised processes but saw “patchy uptake” by clinicians and no documented change in patient outcomes.

Greenhalgh has led work in this area, co-developing the so-called NASSS framework, to provide “an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program”.

It was developed in response to evidence that many promising technological innovations in health and social care are not adopted, are abandoned, or fail in attempts to scale them up or spread them.

In her keynote, she applied to the TORPEDO project three different theoretical lenses on change that she and co-author Vhrysanthi Papoutsi outlined in detail in an article published last month in the BMJ (and summarised in the slide below):

The tricky part, she said, is that it is not really possible to carve up projects or innovations and apply just one of the lenses to implementation or evaluation.

She said:

The point is, analytically, we can separate these things out but when you’re looking at a big program, trying to implement a change, you’re probably looking through all of these lenses and probably more.

Complex phenomena are unpredictable, inherently unsolvable, filled with interdependencies.

Where on earth do you start, for example, with climate change?”

Seven principles

Looking to offer solutions in the absence of a “blueprint” for change, Greenhalgh recommended seven useful principles to adopt when planning major change programs in conditions of complexity (they are  discussed in more depth in the BMJ article).

Some, she said, have been identified by other researchers:

  1. Acknowledge unpredictability: “contemplate that there may be more than one possible future”.
  2. Recognise self-organisation: “expect local teams to play around with whatever you’ve asked them to do and adapt it to something that will work there”.
  3. Facilitiate interdependencies: “and perhaps spot new ones”.
  4. Encourage ‘sense making’ – “bring people together to talk, argue, and raise questions even if they can’t solve things”.

She and Papoutsi had added three more:

  1. Develop adaptive capacity in staff – “Teach your staff to be able to make judgments when the data is incomplete, when things are a bit confusing….”
  2. Attend to human relationships – “It’s a heck of a lot easier to work through problems if you like each other. If you’re working with people who hate each other you’ll never get there.”
  3. Harvest conflict productively – “We talk far too much about resolving conflicts and reaching consensus.” Teams and projects should look to build trust, to be “okay about the fact we disagree and use our different perspectives on the problem to produce a multifaceted solution”.

Asked to summarise her key messages, Greenhalgh said “we need to develop the capacity of individuals to make judgments and use their common sense, to tinker with things, adapt things locally, use their imagination, use creativity, ‘sense make’, to get together and talk about the issues and muddle through with solutions”.

“These are not very formulaic and they don’t sound very scientific but, actually, when you’re working in a complex system, they’re very important.”

“Tell the story!”

Greenhalgh also gave a shout out to Greek organisation theorist Haridimos Tsoukas, whose message is “don’t simplify, complexify” and that “rich narratives allow us to learn by understanding the particular for its own sake rather than as an example of something”.

She said one of his key requirements for writing good accounts of quality improvement or change management is “poetic praxiology” which she interpreted as: “Use good terminology, use metaphors, use imagery to bring it to light – don’t be boring!”.

That too was part of what she wanted Choosing Wisely participants to take away from her address, the need to “tell the story – and in rich detail!”

It’s an approach she’s famously taken, challenging the “spurious hierarchy of systematic over narrative reviews” in both her research and the way she presents her work

That’s included her article published last year in the Journal of Evaluation in Clinical Practice titled: Of lamp posts, keys, and fabled drunkards: A perspectival tale of four guidelines.

In it she examines the tension – “both philosophical and practical” – between the average result from a population study and the circumstances and needs of an individual patient via her own personal account of “evidence-based” trauma care.

A keen athlete, Greenhalgh told how she had suffered major fractures and other injuries in a  high-impact bike accident but, aged 55 at the time, found herself “prematurely assigned to the script of ‘older person with fall’” narrative in her diagnosis and treatment.

Her team has just won a grant from the UK Medical Research Council to look at the narrative case study as a legitimate form of research, and she told Croakey that she doesn’t buy the idea that it’s difficult for scientists or other researchers to tell a strong story.

“I think one of the problems is that when we are trained as scientists and academics, we get trained out of the habit of telling stories,” she said.

“We get told you’ve got to ‘abstract’, you’ve got to produce these things called variables and manipulate the variables and draw graphs and these diagrams all full of boxes and arrows.”

Telling stories is much easier than that, she said, urging academics and scientists to “regain our confidence in the richly described case narrative”.

She said:

Stories have characters, they have plots, they have unfolding action, stories are image rich, they’re emotionally laden, they’re the sorts of things that really kind of hook you in.

I think you need to unlearn all that training, that says ‘no, no, it’s unscientific’.

Tell it like it was, we want all the holes in it, we want the problems, the way people felt, we want the uncertainties.”

“Inspired”

The Choosing Wisely conference showcased a range of initiatives in Australia from tailoring the use of opioids on discharge from hospital and better urine sample collection for young pre-continent children to the first state government-funded “scale-up” of Choosing Wisely in Victoria.

Throughout the day Greenhalgh commented on or asked questions about presentations and posters, and later told Croakey she had been “inspired” by what was happening in Australia.

However, she said that, as a GP with more than 30 years’ experience, she had both observed and been told of a significant gap in Choosing Wisely take-up.

So far, the strongest work was happening in hospitals, despite there being plenty of room for improvement in primary care, where “there is huge potential for over-investigating and over-treating those patients and perhaps over-applying some formulaic approaches”, she said.

Greenhalgh said the primary care sector had been “pivotal” in the rollout of Choosing Wisely in the UK, and she hoped GPs would become more engaged in this movement for change in Australia.

Addressing fake news

In an interview with Croakey, Greenhalgh also warned about the implications to health and health care of “oversimplifying” important public debates and of “fake news”.

She said Brexit, the decision for the UK to leave the European Union, was “a great example of a highly complex issue that has been oversimplified by politicians, the press and by the voting public” into a binary question that was now threatening serious health consequences.

“If Britain leaves the EU without a full agreed deal, I think there is quite a lot of evidence that we are going to have big h