Mindlines and guidelines

In this video I wanted to briefly describe some ethnographic research performed by health services researchers around 10 years ago. Ethnographic research refers to the study of human behaviours or cultures and involves spending time understanding not what people say they do but what actually happens in a “real world” setting. The researchers were embedded in GP practices for a period of time, observing how the clinicians worked both in consultations, and in team settings observing not just formal interactions with patients but the informal chats that are so important for sharing knowledge. They selected practices known to be very high performing and have excellent doctors. They noted that despite a preponderance of guidelines the GPs rarely looked at them.

So how did the GPs make decisions? The researchers described this process by using the term mindlines. Mindlines were described as flexible “guidelines in the head” incorporating tacit knowledge – that is knowledge gained through experience that you may not know you know – as well as formal training, evidence and guidelines, stories and narratives and the social and cultural context the doctor is practising in. The researchers found that these mindlines are created in the interactions between clinicians, patients, teams. They are a form of “practice-based evidence” – knowledge created in practice in context.

These mindlines were created because the GPs were practising in what has been described as the swampy lowlands of clinical practice – where we all are everyday, where patients don’t fit the guidelines and we don’t always have perfect information. Flexible mindlines helped them negotiate this space, where multiple guidelines could not. They also describe how mindlines are created by people working together - a community of practice, where practitioners can learn and support each other and how tacit knowledge can be accumulated through these informal means. The process of learning to provide high quality care is not just learning facts and guidelines but also developing what is called contextual adroitness - this means being able to use knowledge in the social and cultural context.

Maybe it’s just me but have you ever been faced with a medical student who seemed to know the latest guideline or research better than you did? They still wouldn’t have been safe to practice medicine independently because they hadn’t developed the mindlines and contextual adroitness to let them apply their knowledge. If you want to know more about mindlines some links are provided at the end and there is also a podcast on the Wise GP website you can listen to. In our next section we will discuss why we need knowledge work in 21st century medical practice and what barriers we face to trying to practice this way.