Mindlines

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Books: Knowledge Transformation in Health and Social Care. Putting Mindlines to WorkJohn Gabbay, Andrée le May Routledge, 2022, PB, 262pp, £34.99, 978-0367746162 It’s 20 years since the British Medical Journal ( BMJ ) sent me a paper to review with the made-up word ‘mindlines’ in its title.1 The covering email said something like ‘we’ve already decided to reject this paper but could you please quickly skim it and give us some reasons to pass on to the authors?’ I was intrigued. Even the BMJ didn’t usually reject qualitative research submitted by well-known professors without reading beyond the title. I read the paper and told the editor he should publish it as soon as possible because it described the most philosophically important research study he’d ever sent me. A few years later, a different BMJ editor ranked that paper (which has now been cited over 1200 times) among the BMJ ’s top 20 in the 20 years since the journal went digital,2 and in a subsequent BMJ poll it was voted the top research paper. The paper described an ethnographic study of a highly-rated, well-renowned primary- care practice. Two researchers — a doctor and a nurse, respectively, by training, both with an anthropological bent — sat in GPs’ surgeries and nurses’ clinics and watched the clinicians to see how they practised so effectively. And what they watched was good clinicians not following guidelines. Actually, the GPs and other clinicians did use guidelines — just not in the way …

Mindlines: What are they and how can we use them wisely?

We often hear about guidelines in medicine, education, business and other fields. Guidelines are supposed to provide evidence-based recommendations for best practices and help us make informed decisions. But do we always follow guidelines? And are guidelines always reliable and relevant to our contexts?

In this blog post, I want to introduce you to a different concept: mindlines. Mindlines are the collectively reinforced, internalised, tacit guidelines that we use to make decisions in our everyday practice. They are not written down or formally endorsed, but they are shaped by our personal experiences, interactions, culture, values and beliefs. Mindlines can be useful, but they can also be risky. Let’s explore how mindlines work and how we can use them wisely.

How are mindlines different from guidelines?

Guidelines are based on systematic reviews of research evidence, expert opinions and consensus processes. They are usually published by authoritative bodies and updated regularly. They aim to provide clear and consistent advice for common problems or situations.

Mindlines are based on informal and unsystematic sources of information, such as anecdotes, stories, tips, habits and heuristics. They are usually learned through socialisation and observation of peers, mentors, role models and opinion leaders. They evolve over time and vary across individuals and groups. They aim to provide flexible and pragmatic solutions for complex or uncertain problems or situations.

What are the benefits of mindlines?

Mindlines can be beneficial in several ways:

- They can help us cope with information overload and cognitive limitations. We cannot possibly remember or apply all the guidelines that exist for our fields of practice. Mindlines can help us simplify and prioritise information and make quick and intuitive judgments.

- They can help us adapt to local contexts and preferences. Guidelines may not always be applicable or appropriate for our specific settings or clients. Mindlines can help us tailor our decisions to the needs and expectations of our stakeholders and the resources and constraints of our environments.

- They can help us learn from experience and social interactions. Guidelines may not always reflect the latest or most relevant evidence or innovations for our fields of practice. Mindlines can help us incorporate new insights and feedback from our own practice and from others who share similar challenges and goals.

What are the risks of mindlines?

Mindlines can also be risky in several ways:

- They can lead to bias and error. We may not always be aware of the sources or validity of our mindlines. We may rely on inaccurate, outdated or incomplete information or assumptions. We may ignore or dismiss conflicting or contradictory evidence or perspectives.

- They can lead to variation and inconsistency. We may not always agree with others on what constitutes a good mindline. We may have different mindlines for the same problem or situation. We may change our mindlines depending on the context or mood.

- They can lead to resistance and inertia. We may not always be open to change or improvement of our mindlines. We may stick to our mindlines even when they are proven to be ineffective or harmful. We may reject or avoid guidelines that challenge our mindlines.

How can we use mindlines wisely?

Mindlines are not inherently good or bad. They are inevitable and useful aspects of our practice. However, we need to be aware of their strengths and limitations, and use them wisely. Here are some suggestions on how we can do that:

- We can slow down our thinking using cognitive forcing strategies. These are deliberate techniques that help us pause and reflect on our decisions before we act on them. For example, we can ask ourselves: What is the evidence for this mindline? What are the alternatives? What are the consequences?

- We can recognise our own mindlines by reflection, feedback and checking assumptions. These are processes that help us become more conscious and critical of our mindlines. For example, we can ask ourselves: Where did I learn this mindline? How do I know it works? How does it fit with my values?

- We can compare and contrast our mindlines with others’ mindlines by communication, collaboration and negotiation. These are activities that help us learn from different perspectives and experiences. For example, we can ask others: What is your mindline for this problem? Why do you use it? How do you evaluate it?

- We can update and improve our mindlines by seeking new information, evidence and innovations. These are sources that help us keep up with the latest developments and best practices in our fields. For example, we can consult: What do the guidelines say about this problem? How reliable and relevant are they? How can I apply them?

-Adopting a polarity framework to manage key dilemmas in education and assessment design, rather than relying on either-or thinking. This framework recognises that some dilemmas are not problems to be solved, but polarities to be leveraged, by identifying the benefits and drawbacks of each pole and finding ways to achieve the best of both.

-Applying ethical principles and ethical reasoning to guide decision-making in practice-driven ethical dilemmas, such as autonomy, beneficence, non-maleficence, and justice. These principles can help students to analyse the situation, identify the ethical issues, weigh the pros and cons of different options, and justify their choices.

-Engaging in inter-professional education and collaborative learning with peers and mentors from different disciplines and backgrounds, to share and compare mindlines, learn from different perspectives, and develop a common understanding of best practice.

-- The tension between following guidelines and using clinical judgement. Guidelines are meant to provide evidence-based recommendations for common clinical scenarios, but they cannot cover every possible situation or individual variation. Clinical judgement is based on personal experience, knowledge, and intuition, but it can also be influenced by biases or emotions. How should doctors balance these two sources of information and decide when to deviate from guidelines?

Conclusion

Mindlines are similar to experiential learning: they are based on what we do rather than what we read or hear. However, mindlines are not tramlines: they are not fixed or predetermined paths that we have to follow. We can play games with our mindlines, as Eric Byrne suggested, and explore different scenarios and outcomes. We can also use ideas, concerns and expectations as a framework to elicit and discuss our mindlines with others.

Mindlines are not a substitute for guidelines, but a complement. We need both to make informed and effective decisions in our practice. By using mindlines wisely, we can enhance our professional judgment and performance.

Mindlines could be similar to clinical judgement or practice-based evidence and thus do not offer a novel approach to understanding or practising medicine.

Integrative thinking - Wikipedia

https://sourcesofinsight.com/the-polarity-framework-solve-problems-manage-dilemmas/