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.

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(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.