Last few moments in the pod.

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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.