Melancholy, books, and Lobster Risotto

One of my sad duties this week has been to try to make sense of some my books. I'm very old fashioned, I suppose, and believe that the life of a university professor is one that involves books – not as ornaments or signs – but as integral to the work of scholarship. The wonderful new building that is being built for the Institute that I belong to, however, has no space for my books or anyone else's. Indeed, I will have neither bookshelves or private spaces for scholarship. Instead, it is formed through large open plan office spaces - an 'environment' - where I will be able to entertain dynamic relationships with others, sparking off their ideas, find new ways to collaborate, and enjoy the electric excitement of constant collaborative interactions with teams. Sharing an office with 30 other people will bring its own challenges of course, and I'll probably experience these mainly in the business of grant writing and drafting papers and book chapters. These are challenges that, to be frank, cause me a certain amount of anxiety. I've always felt that my modest successes as a researcher – both in generating research income for my own work, and contributing to the generation of income to support others (£17.2 million, to date), and writing (about 180 articles and book chapters) – have stemmed, in great part, from having a private space in which I could read, research, write, and talk to my colleagues without being disturbed or disturbing others. We must embrace change, of course, and there are plenty of reasons why my current accommodation is unsuitable for its present purposes. However, I do envy my colleagues who will get to keep their offices in other parts of the University, and a deep nostalgic regret at the prospect of not having my books at hand to read, and lend, and think about – and of the loss of a private, quiet space in which to talk and work without being disturbed or disturbing others.

So, between now and moving-in day next March, I have to sort through my books and dispose of about 600. Not all can come home. There isn't room in my house. There is, however, an up-side to this which is the process of sorting out in itself. For reasons that I cannot explain, I own a pile of books about Freudian theory. I can't explain this, since I have never taught, written, or even talked about psychoanalysis. They mystify me. And, like about six hundred of their fellows, they are off to universities in the developing world. With them go a number of tomes of Gramscian political philosophy; rigorous interrogations of Heidegger and Foucault; political economies of health, morals, and industry. I feel ashamed about palming off a load of books about the discredited science of Oedipal nonsense, but I can't bear to throw away even books about Freud. Amongst the books I am keeping, I have come across many gems. One example is Leon Eisenberg and Arthur Kleinman's edited collection on The Relevance of Social Science for Medicine (D Reidel: Boston, 1981). This is one of those books that presents in chapters many of the concepts which are now the commonplace and taken-for-granted elements of my discipline. (Rediscovering Andrew Twaddle's chapter on sickness careers in this book, last summer, gave an impetus to the way that I began to try to retheorise the business of illness through the lens of Normalization Process Theory, and so to my contribution to the notion of minimally disruptive medicine.) I saw in last week's BMJ that Leon Eisenberg died the other day. By all accounts he was a 'proper gent' and he was certainly a pioneer spirit in integrating sociology into the medical curriculum. Some years ago I wrote a short paper about the 'invention' of shell shock as a psychiatric condition between 1914-1919, which when it was published in the Journal of the Royal Society of Medicine led to a brief note from Eisenberg. In it he offered some recollections of his clinical work with US army veterans after World War II. They were interesting, but it was the fact that he wrote at all that I enjoyed.

Amongst the other books that I have been looking at are some rather forbidding volumes about sociological Rational Choice Theory. Not the least of these is James Coleman's Foundations of Social Theory (Cambridge: Harvard, 1994). This is a genuinely alarming book, and contains on pp 454-455, the only sociological interpretation that I have come across of CP Snow novel (The Masters, as it happens). These, and some books about economic sociology, exchange theory, and the so-called Micro-Macro problem in sociological theory and analysis, were all drifting towards each other, finally ending up on the same shelf. This was because my Director and colleague Cam Donaldson and I had planned to do some work together to look at the ways in which ideas in medical sociology and health economics might be worked out in ways that would lead to integrated theoretical models. I was rather looking forward to that, because it promised the kinds of theoretical innovation that drive empirical research forwards. However, Cam has announced that he is to leave Newcastle and move to a post at Glasgow Caledonian. Which is another source of the mild melancholy that has overtaken me this evening.

I'm not melancholy about my talk at King's College London last Wednesday, though. I had a terrific time with a very interesting Q&A afterwards. Interestingly, participants at that meeting included NHS managers as well as academics, and they had perceptive and useful questions about our telecare studies and about the application of Normalization Process Theory. In particular, they were interesting in NPT's role as a management tool for thinking through implementation problems. Later, I was taken to dinner at a very nice neighbourhood restaurant in Coin Street, where I had an excellent Lobster Risotto. I recommend RSJ if you venture south of the river. The whole evening was excellent fun, but the night (at the Charing Cross Hotel) was largely spent listening to grim noises from ancient plumbing. Also, someone phoned my room at 04.00 and asked, 'Is that you, gorgeous?' To which I could only say, 'no'.

Time spent with friends

I've been really fortunate to have spent a good deal of time in the company of old friends lately. Last week, in particular, I visited Edinburgh for the second meeting of our NIHR Peer Learning Set for Normalization Process Theory. Last year we met to discuss how we were going to progress the theory, and one of the objectives that we set ourselves was that we would begin to develop an on-line 'users manual' for NPT. Day one of the meeting involved us in reviewing two studies that have pushed the bounds of the theory - work on the experience of depression, led by Chris Dowrick, and Cathy Pope's study of the implementation of NHS Pathways systems for telephone triage. These were important presentations, in part because they suggested how NPT could be a launching point for new conceptual models of processes that are supposed to be well understood, but which are actually much more opaque than we would like to believe. What united these two very different presentations was the way that they touched on the practices - the work - of social construction. This is one of the interesting features of NPT, and it's also one of the problems. Keeping the enterprise within reasonable bounds is a problem for theories of change - in part because change itself raises questions about levels and units of analysis. This is becoming an important focus for the final chapter of the book, Normalizing Health Technologies, that Tracy Finch and I are co-writing. Day one also included a detailed discussion of draft chapters for the NPT on-line users' manual, which is being supported by the ESRC as part of its 'follow-on' funding programme. Shaun Treweek, Tim Rapley, and Frances Mair presented their drafts on clinical trials, qualitative research and systematic reviews, respectively. This was a really congenial day, followed by a good dinner. Day two involved a detailed presentation by Tracy Finch on the operationalization of NPT's constructs, and the development of survey items to measure them. The discussion that followed was important, and our collective work has begun to open up new ways in which NPT can be usefully applied.

As we were having our Edinburgh meeting, the NPM/NPT papers published on-line in BMC Journals passed 20,000 accesses. This is interesting in itself, and I wonder how academic publishing is going to respond to the development of Web 2.0 technologies for dissemination. Or whether it can. One important feature of this is that impact will come to be measured in more than citation counts. These are a really narrow way of assessing engagement with an article or presentation. It also assumes that it is the article that actually matters, when down the line it might be the blog of the article, or the embedded video, or embedded powerpoint, of the article, that are actually the important routes by which research ideas and results are disseminated. Ac

Speaking of dissemination, on 18 November I am giving a seminar at King's College, London. I shall be speaking about problems of implementation and integration of new health technologies, and probably trying out some ideas from the forthcoming book. It's a while since I was last in London, so I'm looking forward to it.

Burden of Treatment

I’ve had a really interesting few days. Mainly this has been about preparing for a Normalization Process Theory masterclass at Glasgow Caledonian University on Thursday evening. This was a really interesting session with a gratifyingly full room and interesting questions and answers afterwards. But it also was an opportunity to talk more generally about the business of theory building, and exploring the constraints on explanations that are developed in relation to programmes of empirical research work. This is a crucial problem – theory writers are rarely as interested in discussing the limits to their work as they are the expanding field of its applications. One of the merits if NPT – as I see it, anyway – is that it is so explicit about its limited scope. This means that it federates with other theories in Science and Technology Studies. Helen Cox’s PhD thesis on ‘Translating Molecular Diagnostics’,supervised by Andrew Webster in the Sociology Department at York University, here in the UK, is a really interesting example of a thesis that ‘nests’ NPT within a broader theoretical framework. It’s a really interesting and well constructed thesis too.

Work combining NPT with attempts to secure Minimally Disruptive Medicine continues, and it’s plain that this is going to be a key clinical application of NPT. The good news is that Frances Mair, Victor Montori, and I have now secured funding for a study that will explore the interactions between Normalization Process Theory as an analytic perspective and minimally disruptive medicine as a policy objective. We will be exploring the ways that people with heart failure make sense of the work of being sick and integrate it with the work of patient-hood. This is really exciting, and promises to grow our collaboration into an even more interesting body of international work. I’m thinking that next year we should have a seminar to bring together the three groups of ‘burden of illness/burden of treatment’ researchers working across heart failure, depression, and multiple co-morbidities. That would be a groovy treat!

I’ve mentioned Lee Aase – social media guru at the Mayo Clinic – before and no doubt I’ll mention him again. He’s really generous with his knowledge, and hugely helpful in the way he explores and explains social media. This week he was talking at ementalhealth 09. Interestingly, he used the way Mayo presented our Minimally Disruptive Medicine article in the BMJ on Twitter as an example. Here’s a link to his presentation. And here’s another link, this one’s to a presentation about pecha kucha – speed powerpointing – with some interesting thoughts about empathy and signs.

Conceptualizing depression in the Sierra Nevada

Over the past few days, four of us have been working through the problem of depression at Chris Dowrick's house in the Sierra Nevada (left). Our aim was to explore depression not by reference to the phenomenology of suffering or distress, but by engaging with the work that people need to do as they engage with depression. Our conversations were dominated by the recognition that depression is much more than a biomedical construct, and that it is a deeply embedded artefact of western culture. Our discussions were founded on data - we worked through transcripts, aiming to form our conclusions around a set of analytic propositions that we could then test against new data. This

kind of conceptual work is interesting, but also it's unusual. Most of the research in our field is

driven by data collection - but we're awash with results that reflect old orthodoxies. Now's the time for social and clinical scientists to work towards producing and applying new explanatory frameworks and for rethinking old problems. We had some great conversations - I've not laughed as much for weeks - and some great dinners with good local wine and fresh peasant bread and cheese (bottom photo, left to right: Linda Gask, Anne Rogers, Chris Dowrick, Carl May).

Our way of working through this problem, as I mentioned a couple of weeks ago, has been to use Normalization Process Theory as a framework to think about the work that sick people need to do. Because NPT was developed as a theoretical model to understand socio-technical change in organizational contexts, I had never thought that it might be used to understand individual illness experiences. But there do seem to be interesting opportunities here, because NPT helps us to understand the work that people do as they seek to make sense of their illness, and as they join themselves and others to it, and operationalize the knowledge and practices that surround it. An interesting point here is the way that the sociology of health and illness has so little to say about getting well. The business of sickness is often conceived of as chronic and inevitably degenerative. As I say, we need to rethink old orthodoxies.

Walking in the rain, thinking about illness as an action orientation

The past few days we have been on vacation in the West of Scotland. The back end of September is no time to expect sun, but we saw plenty of rainbows and walked the length of Glen Orchy in some of the heaviest rain I have ever been drenched by. We rented a wing of Bonawe House (left) and ate at two really good restaurants – the Airds Hotel at port Appin (a temple where food is not so much enjoyed as worshipped), and Coast in Oban, which does pretty spectacular Scottish contemporary cooking.

Although I was supposed to be on holiday I was actually emailing back and forth, and reading transcripts, about three really interesting and closely interconnected projects in which we’re using normalization process theory to explore the work of being sick, our starting point is a piece written for a book edited by Graham and Sasha Scambler. The collection won't be published until next May, so I have put the chapter up on my academia.edu page.

First of all, a group led by Chris Dowrick, and including Carolyn Chew-Graham, Linda Gask, Jane Gunn, Anne Rogers, and I are using NPT to examine the work of being depressed. The aim here is to explore depression from an action orientation and to locate novel points of therapeutic intervention. This is really interesting and we’re shortly off to workshop through a set of transcripts and start building testable hypotheses in the splendid surroundings of Chris Dowrick’s hacienda at Molina Canario. This international group has its counterpart in a group led by Victor Montori at the Mayo Clinic, who is leading a programme of work that explores the burden of work in chronic illness and comorbidity, again using NPT, but combining it with our work on Minimally Disruptive Medicine. Being involved in this group is very interesting, the aim is to identify ways of measuring treatment burden and thus enable clinicians to respond to structurally induced non-adherence to treatment regimens. Finally, Frances Mair and I are working with Katie McGrath – a really interesting early career research in general practice – to develop an NPT based analysis of the interaction between burden of illness and burden of treatment in people with chronic heart failure. These three studies all seek to analyse the experiences of sick people from the perspective of their active engagement with healthcare systems and their experiences of doing the work of healthcare for themselves. It's a really interesting application of NPT, which I originally envisaged as a theory of socio-technical change. But now, one of the possibilities that it raises is a rigorous and theoretically informed of the implementation and integration work that people do when they engage with their own illness as active participants in processes of sense-making, cognitive participation, and collective action. It's very exciting.

About Social Systems - just briefly

For reasons I shan't trouble anyone with, I am working my way through Niklas Luhmann's grand opus Social Systems (trans J Bednarz Jr & D Baeker, Stanford University Press: Stanford CA, 1995). Luhmann is unique amongst European social theorists in that (i) he owned a pub, and (ii) he owned a brewery. But, God alone knows, he found it hard enough to write an engaging sentence.

I bought Social Systems last week in the wonderful Munro's Books on Government Street in Victoria, BC. There are some things to be said about Social Systems, however. It's not so much a book about social theory as a giant casting press, imposing its great weight on smaller more fragile objects and crushing them into unwilling shapes.

Against Luhmann, Parsons on The Social System and Habermas on Communicative Action both seem to be formed from satirical and succinct prose (which they are very definitely not, incidentally). Even Foucault pales into simplicity next to the violent disregard that Luhmann has for the reader. Luhmann's book is utterly relentless; incomprehensible in some parts; grindingly dull in others. Trying to make sense of it is like working a large and very heavy electric polisher over an uneven strip of parquet flooring.

The value of social media

The Mayo Clinic has just put video of its 2009 Transform Symposium on line. This includes talks by Maggie Breslin and Victor Montori - Victor gives a great presentation of our ideas about Minimally Disruptive Medicine, as discussed in earlier blogs. One of the things that my collaboration with Victor and his colleagues in the Knowledge and Encounter Research Unit has brought home to me is the value of different social media - YouTube, Web 2.0, and even Twitter - in ensuring public and professional engagement with their work. Mayo has an incredibly perceptive and effective social media guru in Lee Aase, and he provides an extraordinary free resource for people interested in developing social media skills and capability.

On the Pacific Rim

For the past week I have been in Victoria, British Columbia, participating in a workshop that ought to lead to major centre for health services research on the Pacific Rim. Led by Mary Ellen Purkis and Lynn Stevenson the workshop focused on how a university and a health authority can build a genuine partnership to answer questions that have both a scholarly and a policy edge. In lots of ways, it was a thrilling meeting because of the Vancouver Island Health Authority’s initiative to redesign patient care . This is a major, data driven, enterprise founded on more than 30,000 hours of observational work, and recording about 1.5m episodes of patient care. It’s a very exciting resource for research and it will be at the centre of the new centre.

While I was there, I had the opportunity to renew my acquaintance with Chris Ceci of the University of Alberta, as well as Mary Ellen, and ended up writing an Introduction for their edited volume of papers presented at In Sickness and in Health 2009. While I was in Victoria I had a chance to eat at the inestimable Café Brio - one of my favourite restaurants in the world. They served a fantastic Fig and Goats cheese salad to start (it’s going to figure prominently on my Menu this winter) and a truly excellent roast duck on pureed Jerusalem Artichoke.

Theory, Practice, and STS

Working on Chapter 3 of Normalizing Health Technologies, I've been musing on the problem of agreement about fundamental problems of practice in Sociology. For example, we can find representatives of very different perspectives – for example, John Goldthorpe [1], representing rational choice theory applied to large population data-sets; and John Law [2], representing actor-network theory in ethnographic case studies – arguing that the integration of theory and empirical research is a core problem.

Traditionally, STS practitioners have usually been cautious about theory in the form of grand narrative. (…) They tend to speak somewhat austerely, to want to know both what large scale generalisations or theories mean in practice, and about where they apply. Indeed, they are prone to ask whether such generalisations mean anything at all. They also, and in a related way, tend to avoid buying into a theory/data distinction. This is because in STS theory is not first created and then applied empirically. Theory and data are created together. However empirical it may be, everything is already theorised (2008: 629)

This implicit theorisation is both inscribed in the meanings and assumptions that are designed into technologies like telemedicine – in this case that clinical encounters can be lifted out of the clinic, and be made more efficiently and equitably available that are by the people who are implicated in those practices, and in the cognitive and behavioural ‘toolkit’ that those people draw on in their everyday lives. So, one task for sociological analysis is to engage with those implicit cognitive resources and to find ways to make them explicit. But for Law and others, the business of STS is also about breaking down distinctions between data and theory, and saying that STS analysis is about the co-production of theory and data in relation to some empirical topic.

Law wants to avoid social science in which the empirical world is divided off from the world of theoretical development – like many sociologists (me included). He’s also anxious that the methods of sociological research come to constitute the realities that sociologists seem to engage with. Foucault’s dictum, that ‘discourse constitutes its own objects’ [3] applies here. So, to read theory in STS is to read the literature of cases studies. It is in this context that theory is developed as the empirical world is described and understood. An approach in which ‘theory’ and ‘data’ are co-produced and interwoven, then, is at the heart of Law’s analysis of the strengths of STS.

I think this is true of the work of a very small number of theoretical innovators including Law, but also – and especially the astonishing Sociological imagination of Michel Callon [4, 5]and Donald Mackenzie [6-8], both of whom have become interested in the sociology of maths, markets, and machines. However, it is much less clear that this is, in practice, what happens more generally. It's certainly not what I see as a reviewer for journals like Social Science and Medicine. In fact, just as in other areas of theoretically informed social science investigation, we see multiple instances of the transportation of basic constructs of a theoretical perspective from empirical setting to empirical setting. They don’t change much as they move between them, and slowly the socio-technical world becomes framed in relation to such constructs. It's hard to have a sociological conversation now about a new technology without addressing the problem of how the network is stabilized or not.

1. Goldthorpe, J.H., The integration of sociological research and theory - Grounds for optimism at the end of the twentieth century. Rationality and Society, 1997. 9(4): p. 405-426.

2. Law, J., On sociology and STS. Sociological Review, 2008. 56(4): p. 623-649.

3. Foucault, M., Afterword: the subject and power, in Michel Foucalt: beyond structuralism and hermeneutics, H.L. Dreyfus and P. Rabinow, Editors. 1986, Brighton. p. 208-226.

4. Callon, M., C. Meadel, and V. Rabeharisoa, The economy of qualities. Economy and Society, 2002. 31(2): p. 194-217.

5. Callon, M. and F. Muniesa, Economic markets as calculative and calculated collective devices, C.U. New York Conference on Social Studies of Finance, Editor. 2002.

6. MacKenzie, D., Mechanizing Proof: Computing, Risk and Trust. 2001, London: MIT Press.

7. MacKenzie, D., Knowing Machines: essays on technical change. 1998, London: The Massachusetts Institute of Technology Press.

8. MacKenzie, D., Inventing Accuracy: A Historical Sociology of Nuclear Missile Guidance. 1993, Cambridge, Mass: MIT Press.

Catherine Pope

My friend Catherine Pope is promoted to full professor from today.

Hurrah!

More minimally disruptive medicine

Minimally Disruptive Medicine is beginning to gather momentum. Here's a video of co-author Victor Montori, talking about MDM at the Mayo Clinic. He's a great speaker.

It's more than a case study

I’m a medical sociologist – which is to say that I am interested in the knowledge, practices, and social relations that underpin medicine as a social institution; and in health care as the matrix in which it is set, and the ways that it is linked to other social institutions. I’m also interested in the history and sociology of technology – hence my focus on the development of explanatory models of socio-technical change, discussed in other posts. My small contribution to this field has been to lead a programme of work that has led to the development of Normalization Process Theory.

From my perspective, one of the interesting features of sociological research around health and illness over the past decade has been the growing significance of the broad field of Science and Technology Studies, or STS. A number of commentaries – of which a paper in Health Care Analysis by Casper Jensen is the most recent – have argued that a shift to the theories and methodological perspectives of STS is necessary to secure the intellectual future of ‘medical’ sociology. My research and writing has certainly been influenced by STS although – it seems – not enough for Jensen. In some ways, STS seems to have a good fit with the ways that Sociologists of Health and Illness construe their own field of research. In the UK, at least, the boundaries between the two fields are getting a bit blurred.

Now, STS is constructionist in its theoretical approach; privileges contingent and relational aspects of social life; focuses on specific incidents or cases of general problems; and is largely conducted through the application of qualitative research techniques – often ethnographies, and increasingly also interview-based research. But, as John Law has argued in a recent position paper in Sociological Review, there is a strong argument within the communities of practice that make up STS that it ought to concern itself primarily with case studies, description and classification, and that it should seek neither causal explanations nor should it attempt quantitative generalisation. Actually Law may go further than this. He seems to say that this is the way that we should think about sociology as a whole discipline. I think this is a counsel of despair; a recipe for empirical fragmentation; and a prescription for the loss of analytic power. The multiplication of small-scale, qualitative, case studies of contingencies and relational processes restricts the development of Sociology as a holistic science of social and material relations. If everything is a case, then nothing is a whole.

As a brief aside, the BiomedCentral papers describing Normalization Process Theory passed 18,000 on-line accesses today.

Predictions

Prediction is a notoriously complex task in the social sciences. In sociology, many are opposed to it. After all, social processes of all kinds are complex and emergent. This means that their outcomes are hard to forecast. Social processes are also complicated because of contingency. Because of this, some methodologists have argued that the only effective means of prospectively evaluating the outcomes of social processes is by employing simulations of different kinds. These constitute ideal type social processes, based on rules (simulated norms), which can run through many thousands of iterations and reveal interesting features of self-organising systems.

Although sociologists have tended to treat predictive studies with scepticism, arguing either that they are methodologically impossible, or that they are not the business of sociology, prediction is the Holy Grail of all of the social sciences. One reason that I am interested in Normalization Processes is because they seem to suggest some basic criteria for forecasting the outcome of implementation processes. I say forecasting rather than predicting because it seems to me a looser term. Absolute prediction is a problem in all sciences that involve the analysis of complex systems, partly because it is not clear what is to be predicted. The interesting problem to me is that many social processes are both self-organising and self-confounding. Sometimes organisation and confounding are simultaneous, and simultaneously include the same actors and actants. In this context, forecasting might be more possible. After all, some humans seem to be able to make correct judgements about the outcomes of social processes on the basis of limited information and without foreknowledge of disorganising factors, future contingencies, and external confounders.

The burden of palliative care

A very thoughtful and interesting post on the PalliMed blog discusses the clinical implications of our recent BMJ paper on Minimally Disruptive Medicine. Even though this hasn't appeared in the hard copy of the journal yet, I've been really pleased by the postive responses not to the paper - not least from some of my own colleagues here in Newcastle. For me, one of the key conceptual issues that has arisen out of this is how to understand the complex relationships between the burden of the lived experience of illness and the procedural and practical burden of treatment. It's quite clear, when we make up an NPT matrix for Minimally Disruptive Medicine that professionals and patients end up doing different kinds of work. That is an empirical as well as a practical problem to pursue later on.

The straight gaze of autoethnography

An extraordinary paper by Mildred Blaxter published this month 'on-line' early in Sociology of Health and Illness, explores her experiences of diagnosis and investigation for lung cancer. At the centre of the paper is the problem of how the 'patient vanishes' as the evidence for disease is assembled and accumulated. Like everything Mildred Blaxter ever wrote, it is beautifully composed and written, and the paper follows a coolly analytic line, taking moments that are emotionally meaningful and very complex and subjecting them to a straight gaze. This is how autoethnography should be written, developing theoretically generalizable critique and concepts from a moment by moment case-study.

Credit where credit is due

As a PhD student at the back end of the 1980s I came to be suspicious of ‘grounded theory’ studies and carried on feeling that way even though the constant comparative method that underpins grounded theory building has been my main methodological commitment for my whole career. I saw Grounded Theory (1) as a step backwards. Although I don’t necessarily hold with all of the technical procedures that drive GT, increasingly I think it is a really good model for work that integrates empirical investigation and theory-building research, and I approach GT much more sympathetically. I’ve looked again at how Barney Glaser and Anselm Strauss were able to draw from their ethnographic studies of medicine and health care a set of substantive theoretical constructs about trajectories and then they worked these into a formal theory of Status Passage. Although it’s nearly 50 years old, it’s elegant, parsimonious and interesting. It’s hugely relevant to some of the problems we investigate today in medical sociology, especially around the experience and management of chronic illness.

I stayed suspicious of GT because so many of they studies that have claimed grounded theory, actually deliver nothing of the kind. Instead they offer a set of empirical generalizations – regularities in the data that call for theoretical explanation – rather than theoretical explanations in themselves. In this context, it’s scale that is important. Empirical generalizations may be all that it is possible to achieve, inductively, in the kind of small scale qualitative study that are the most common examples of the species in medical sociology. But GT, as set out by Glaser and Strauss did not come about through such studies. Instead, they drew on, and drew together, comparative analyses on a large scale. Status Passage, for example, draws on three large studies in which Strauss was a senior investigator – Boys in White (2), Psychiatric Ideologies and Institutions, (3) and Awareness of Dying (4) – to develop a theory of personal trajectories. These were large programmatic studies, consisting of many field researchers conducting hundreds of interviews and observations in a very intensive process of data gathering and interpretation-in-action. Individually and together, these studies made major theoretical contributions to the development of medical sociology as a field and they did so by cumulative and comparative theoretically informed analysis. When I started drawing together my own studies to build up a theoretical model (5) I ended up doing something close to Grounded Theory-building as it was described by Glaser and Strauss. Close enough, in fact, to need to call it that and give credit where credit is due.

_______________________________________

(1) Glaser BG, Strauss A. The discovery of grounded theory. (Chicago: Aldine, 1967)

(2) Becker H, Geer B, Hughes EC, Strauss A. Boys in white: student culture in medical school. (Chicago: University of Chicago Press, 1961)

(3) Strauss A, Schatzman L, Bucher R, Ehrlichman D, Sabshin M. Psychiatric Ideologies and Institutions. (New York: Free Press, 1964)

(4) Glaser BG, Strauss A. Awareness of dying. (Chicago: Aldine, 1965)

(5) May C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Services Research 2006; 6: 1-11

Minimally Disruptive Medicine

One of the features of my work, first of all around chronic disease management in primary care, and then around telemedicine and related technologies, is the sense that patients are increasingly burdened by the delivery, management and organization of their own treatments. This is especially true as the 'self-care' revolution takes off. With Victor Montori and Fances Mair, I have proposed that we need Minimally Disruptive Medicine. The aim here is to accept that the burden of work transferred from the clinic to the home is growing steadily greater, and that the burden of illness plus the burden of treatment may be too great for some people to bear. This is especially the case as a growing population of older people suffer an increasing number of co-morbidities. This view stems from the ways that we are using Normalization Process Theory to think about the new kinds of healthcare work that are implemented, embedded, and integrated, in everyday life - and which are crossing the boundaries between the clinic and the home.

Open access at last....

Six weeks after it was published on the subscription only website, Sage publications have finally released the open access version of our paper giving an Outline of Normalization Process Theory in Sociology.

An interesting week begins....

One of the more interesting outcomes of the collaborations that have developed around Normalization Process Theory comes to fruition on Wednesday, when my paper with Victor Montori and Frances Mair on Minimally Disruptive Medicine is published on-line in the British Medical Journal. Today the BMJ are putting press release on the embargoed BMJ page of EurekAlert, the website of the American Association for the Advancement of Science. We think this is important work and we'll be discussing it, and its implications, in the MDM blog (and mirrored here) once the embargo on publication passes.

Duplicated effort

Just about every university in the UK has an 'institutional repository' where staff and student publications are deposited for open access. Why so many, why duplicate all this effort and expense? Why can't we have national repositories - the British Public Library of Science, the British Public Library of Social Science, and so on for the Arts, Humanities, Medicine, etc. 

Putting the book together

Just like runners, writers have a length to which they seem naturally suited. For me, it's about 8000 words - the perfect length for an article in Social Science and Medicine or Sociology of Health and Illness. So for me, beginning to assemble something ten times that length is a purgatorial. I say assembling, rather than writing. Much of what will appear in May and Finch's Normalizing Health Technologies has already been written in one way or another. So I am arranging and organizing what has already been composed and identifying the gaps. 

What's purgatorial about writing a book? I'm immensely privileged, of course. I'm being paid to put our thoughts down on paper, Tracy Finch and I have a publisher arranged (Palgrave MacMillan), and funding for a conference in London next year when we will be able to launch the book alongside the web-enabled toolkit and users manual for Normalization Process Theory. So in some ways, it's a pretty spectacular deal. We're privileged too, because we're getting in near what may be the end of the paper book.

Nothing is ever enough, of course, and so I'm complaining about having to identify the gaps. Our book is part research monograph (reporting on a ten year program of research on telemedicine in the UK) and part introduction to a theory of implementation, embedding, and integration of new technologies/techniques. So the 'gaps' may actually be the spaces where the links between the two come alive. We'll have to wait and see. I think that's what I'm aiming for as I assemble the parts and glue them together with new writing. 

There are some important questions that need to be answered. The book has to do this, I think. One is about the relative location of Normalization Process Theory and other relevant theories - especially Diffusion of Innovations Theory and Actor Network Theory - and how much coverage to give them. We're locating our work in the Science and Technology Studies tradition - and I see the Wikipedia entry for STS places my work within the 'turn to materiality' - but it plainly doesn't quite fit with STS. That's a more complex problem that probably won't get solved in the book. I'm lucky though - I have a lovely garden to work in on a sunny day.

Finally, my friend Carolyn Chew-Graham has been promoted to a personal chair in general practice at Manchester University medical school. Wonderful news....

Doctors, nurses, and their patients.....

Something is troubling me. I've spent the best part of twenty years with research on professional-patient interaction as a focus of my academic work. I'm very familiar with the professional discourses of contemporary healthcare - they emphasise personal care, continuity, management, choice, quality, engagement, empowerment. These are discourses that run in the background of my work on innovations in health technologies too. There are measures of the quality of interaction, of the degree of continuity in care, and of the extent to which treatment decisions are shared and negotiated.

As my friends and I move into middle age, we find ourselves talking about our experiences of health and healthcare more. These conversations seem to me to be messages from a different planet. They're often about struggling to accomplish complex business in a 10 minute consultation, encountering often uninterested and sometimes rude primary care physicians. They're about long waits and interminable queues. The sense we have is not that we are customers, or patients, but that our primary role is to wait in line. We can easily spend six hours queuing for twenty minutes interaction with a hospital doctor, but we may find that our doctor is completely and obviously indifferent to us. But the real sea change is in the way that people talk about nurses. Nurses - especially in hospitals - are no longer 'angels'. Not at all, they're often spoken of with a bitter hostility that's hard to fathom. Unless you're trying to get basic care for an elderly parent, that is.

Doubt and Sarah Palin

Perhaps the thing that defines modernity best is radical doubt. Contemporary ideas about what it means to be an experiencing and knowing person - so wonderfully traced through their historical trajectories by Charles Taylor in Sources of the Self - reflect constantly on a kind of agnosticism and uncertainty. At times like this - when capitalism is in crisis and politics is a moral ruin (in my country, anyway) certainty of any kind is a problem, and faith in the future deeply unfashionable - then doubt is in command.

All around us doubt is institutionalized. Doubt about the identity and probity of citizens is a critical element of the modern State, doubt about the propriety of financial transactions and the truth of claims is central to the direction of prudent commerce. Doubt about matters of faith and science is built in to the social mechanisms of multi-cultural societies and the funding mechanisms of the academy. Doubt is everywhere - always excepting the processes of Darwinian evolution as they are currently understood, where no matters of doubt are permitted amongst otherwise rational doubters.


And then there is Sarah Palin. A person for whom doubt itself is in doubt. She is giving up to be strong. Quitting to carry on. Not retreating but advancing elsewhere. She has no plans except the plans she has. She wants to serve but objects to politics. It's hard to understand what forces are at work here. It seems to me that in a time of doubt, Sarah Palin has nothing to fear except doubt itself.


For those that prefer rigorous doubt to Sarah Palin, I recommend Jennifer Michael Hecht's Doubt: A History, (Harper Collins: San Francisco, 2003). This is a beautifully written book, by an author who wears her considerable learning very lightly.

Lord Dahrendorf

Ralf Dahrendorf died today, aetat 80.

Death, thou hast lost thy sting

In the strange and wonderful world of PoMo critique we find that even death has lost its sting. The Times Higher Education Supplement tells us, in an account of the fabulous world of Facebook:

 Facebook initiates unintended consequences or messages. Introducing innovations that disembody interpersonal dynamics, it is changing the public attitude not only towards death and mourning, but also towards friendship and interaction. The stark immediacy of the form affects our very processes of thought and imposes different ways of seeing, of understanding and of being in the world. Facebook is a medium whose very characteristics distort relationships by creating an environment and a conversation that is as elusive, transient and disembodied as death itself.

So. Death is transient, elusive, and disembodied. There's some news that we're going to have to get our collective heads round! 

Howie plays jazz

Howard Becker - one of the greatest of America's sociologists - has a great website too. It's filled with intereesting things, including links to a a fair number of his papers and also to a recording of him playing jazz piano. As personal websites go, it's a work of great modesty.

Final versions of Normalization Process Theory papers now published

Two key Normalization Process Theory papers have now been published in final form, and the manuscript versions previously available on my academia.edu page are going to be taken down soon. The published articles can be found at:

May C, Finch T: Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology 2009, 43(3):535-554.

May C, Mair FS, Finch T, MacFarlane A, Dowrick C, Treweek S, Rapley T, Ballini L, Ong BN, Rogers A et al: Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science 2009, 4(29).

both are made available on an open access basis - if you can't get to them through these links let me know and I'll email you a copy!

A bear

Here's a family sitting down to watch television with a bear. That's not something you see very often......

Telecare, ethics, aging

Maggie Mort and Celia Roberts have edited a special edition of Alter, with papers exploring the socio-technical and ethical problems of telecare in an aging population. It can be found here - and it's an important special edition because so few studies of telecare and telemedicine seriously engage with the people who use them. This has been a longstanding problem, one where the 'patient satisfaction survey' has tended to be a substitute for genuine engagement between service providers, designers, and the citizens that use telecare systems. It's a mystery why service providers don't take it more seriously, when it's long been established that genuine involvement and engagement are predictors of successful service interventions.

Objects and subjects

In the social sciences subjectivity is critically important. One of the key achievements of rational choice theory in economics has been to use the language of calculus to present highly contingent and subjective constructions as though they were real objects. Other social sciences, especially sociology, have centralized the notion of subjective meanings and torn away at the ‘taken for grantedness’ of everyday life. Peter L Berger writes in Facing up to Modernity (New York: Basic Books, 1971), that these subjective meanings are useful precisely because they are buried and taken for granted – it would be intolerable, he says, if we had to search for the meaning in everything.

Before the late 1800s the notion of ‘objectivity’, as we understand it, at least, would have been incomprehensible. Mid-19th century scientists sought to be truthful, dispassionate, and disinterested – but do not seem to have drawn a clear distinction between objectivity and subjectivity in the way that we do today. This is a distinction that plagues the social sciences, and especially sociology, in a quite unhelpful way. Positivism, false objectivity, and objectification are now constituted as some of the sins of the sociological universe. Interrogating subjectivity – and subjective self-identity – are now central to the sociological project. Everything is contested – in the practices of knowing, and in the practices of representation. It is this problem that Lorraine Daston and Peter Gallison’s wonderful book Objectivity (New York: Zone, 2007) takes as its topic. They chart the history of the ebb and flow of object and subject in science over the course of a century and a half – from Arthur Worthington’s observation of water droplets to images of nano-tubes. At the centre of this book is the problem of the retreat from personal observation and subjective knowing that underpins some of the natural sciences in the 20th century. The account is framed with scholarship and modesty. It figures prominently in the CBC Radio series How to think about Science, which is available on-line here.

Publishing in open access journals is the way of the future. Indeed it's difficult to see a future in which academic publishing looks the way it does now. I'm writing a book for Palgrave at the moment, but I wonder whether - if I write another book - I won't prepare and format the manuscript myself, and then publish it directly as a pdf through scribd or as kindleware. That way I get to own not only the whole product, but also the whole process, and the timetable that governs it. But not only that, the product itself ceases to be fixed. The manuscript can be amended, on the go, in the light of new thoughts and findings, and authoring processes can be shared in new ways using google wave or wikis like those provided by pbworks. How cool is that?

Another advantage of open access journals is that one can have a sense of the frequency and density of readership - simple data about numbers of accesses are provided by BioMedCentral.com for articles published in BMC journals. I knew Normalization Process Theory was worth pursuing when the first paper was accessed more than 1000 times in the month after publication in the on-line journal BMC Health Services Research. Taken together, the NPT papers on BMC have now been accessed more than 15,000 times through the BioMedCentral portal alone. 

Readership data is interesting because of what it tells you about trends, but it's hard to make more sense of this. I'm on the editorial boards of Sociology of Health and Illness and Nursing Inquiry, and publishers' data for those journals distinguishes between most cited and most read. This kind of data is available on the web for many journals. I find that some of my papers that have hardly been cited have been read in large numbers, suggesting that they are more useful to students than researchers. Which is great. It would be interesting, wouldn't it, if readership, not citation data, was used to assess research quality?

Back and forth to Cardiff

I've been to a very interesting workshop held by Glyn Elwyn and colleagues at Cardiff University. It was really good fun - the object being to think through the 'grand challenges' for telecare over the next decade. Douglas Robinson from Paris did an interesting talk on Multi-Path Mapping, I did Normalization Process Theory, and then there were animated discussions. I learned a lot and came away with some ideas about things that I hope one day to have enough time to write about. 

The taxi into town from the airport was interesting.... As we climbed into the car the driver said, apropos of nothing, "I've got a story for you, about pies....." And then launched into a long discourse about the fine cheese and potato pies to be had at Kidderminster Harriers' football ground. I found my mind drifting. Suddenly (several miles later) I felt him grip my arm tightly and he said, "and then I was seized with panic. Well, wouldn't I be?" I had to agree that he would be. But for the next 24 hrs I wondered why. What had I missed?

Sociology and the evidence base

Another post that I have recovered from the wreckage of the 'Great Blog Crash of 2008'

Some time ago, a colleague remarked that he hoped that, in the Institute in which I work, research would be “less critical and more evidence-based”. I’ve thought about this a great deal, partly because as time has passed, I think my work has become more, not less, critical. The idea of an ‘evidence-base’ seems to make social scientists both excited and anxious. On one hand, it promises us a place at the table. Our work can inform policy – and the more it informs policy, the more that resources and prestige seem to flow from it. On the other, it ties us to a particular kind of program of research, making evidence for policy – one that in the UK has been effectively nationalized, and tied to a set of policy imperatives. But it also ties us to a set of political processes that decouple the analysis of data (something that academics do) and its interpretation (something that policy-makers do). In the impulse to make ‘evidence’ we risk regressing to method and technique as the central scholarly problem. The more we focus on technical problems of practice, the less we focus on explanation and theory.

Evidence only works as evidence if it is engaged with explanation. This week, I’ve been relaxing and recovering from double vision, by reading Stephen Kern’s ‘Cultural History of Causality' (Princeton, 2004). Kern has a wonderful take on this problem. He examines the ways in which ideas about the causes of human behaviour have changed since the 1830s. He explores the impact of theories from the psychosocial sciences as they impact on explanations for action. The twist is that he uses examples from detective fiction to give bite to his argument. There’s a second twist, by focusing on individual acts of aberrant behaviour (mainly murder), what Kern shows, is the complexity of individual action and its integration within patterns of collective action. Kern’s analysis is an interesting and useful antidote to the grinding orthodoxy of much Foucauldian scholarship about ‘social construction’, and is also a useful reminder of the enervating and convincing patterns of explanation that arose from earlier – phenomenological – constructionist theory in the 1960s. In particular, it draws back to the work of Peter L. Berger, and the problems of how realities are constructed in practice by their participants. That is the constant engagement and interdependence of individual and societal, and – as Kern emphatically announces on the final page of his wonderful book – how little we yet know about this, and how much more we have to learn.

The genome and social structure

Beautifully written and very interesting indeed is Daniel Adkins and Stephen Vaisey's recent paper, 'Toward a Unified Stratification Theory' Sociological Theory, 27(2): 99-121. They make a fundamental point, and they make it very well. This is that "while both genome and social background influence the status attainment process, the relative importance of these factors is determined by the surrounding structure of the society (p99)" What follows from this is a clever debunking of genetic determinism, and, I would guess, a nice proto-rejection of the kinds of biological reductionism that also underpin the growing paradigmatic claims of the neurosciences. It's a paper worth reading.

'Unification' is an interesting theme in recent sociological writing, and I'd draw attention to a previous 'Paper of Note' which was lost when my blog crashed at the end of 2008 and all text was lost. This was Guillermina Jasso's wonderful article, 'A new unified theory of sociobehavioural forces' in European Sociological Review (2008, 24(4):411-434). If ever a paper might have encouraged me to give up ethnography and discourse analysis in favour of mathematical sociology, then this was it.

Developing an on-line resource for Normalization Process Theory

Normalization Process Theory enables clinicians and managers to understand the dynamics of embedding new healthcare techniques and organizational changes in context. In the UK, the Economic and Social Research Council (ESRC) has now anounced that it will fund the development of an on-line users manual and web-based tools that will assist researchers, clinicians, and managers in employing NPT. This is a major investment by the ESRC, and over the next 12 months it will involve authoring an on-line users' manual for NPT, developing a set of web-enabled tools for users, and will conclude with a major symposium.

Investigators on this project include: Frances Mair, Elizabeth Murray, Carl May, Shaun Treweek, Tim Rapley and Tracy Finch. International collaborators include Anne MacFarlane (NUI Galway), Luciana Ballini (Bologna), Jane Gunn (Melbourne), Mary Ellen Purkis (Victoria), France Legare (Montreal), and Victor Montori (the Mayo Clinic).

The protocol for the project is available at http://www.newcastle.academia.edu/CarlMay

Developing Theory

One problem for students and researchers interested in evaluating theories in the social sciences is understanding the trajectory of their development. Because theory is so important in explaining and understanding social phenomena we need to know how they are put together and operationalized. This helps us adjudicate on the claims of theorists about their work, its validity, and its practical usefulness. After all, there's nothing so practical as a good theory!

The network of researchers that has coalesced around developing Normalization Process Theory has just published a paper that describes the work of defining and developing NPT - it shows how the theory was organized and enacted practically in a series of well defined discrete tasks that ran from the development of a set of empirical generalizations about telemedicine systems to a fully formed middle range theory of implementation and integration

The paper is available here: May C, Mair FS, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science. 2009;4(29).

Normalization Process Theory News

The NPT site (www.normalizationprocess.co.uk) has been really successful. Much more successful than any of us expected, in fact, and now gets several hundred views a month. Part of this is a result of Dan Pargeter's NPT Wikipedia entry lining directly to the site. Access stats for the NPT wkipedia page site show a steady increase in interest too. The next NPT paper will be published in Sociology in June 2009. It will be the first 'Open Access' paper published by that journal - which is also an achievement. It's currently available as a manuscript for download from my academia.edu page.

I am heading off to Victoria, British Columbia, today to present at 'In Sickness and In Health' which is a great conference run by Mary Ellen Purkis and friends. I shall be talking about sickness careers and sickness work, picking up on some of Talcott Parsons' work about sick roles. I'm looking forward to that - but not to the 18 hour journey!