In this paper we argue that knowledge in health care is a multidimensional dynamic construct, in contrast to the prevailing idea of knowledge being an objective state. Polanyi demonstrated that knowledge is personal, that knowledge is discovered, and that knowledge has explicit and tacit dimensions. Complex adaptive systems science views knowledge simultaneously as a thing and a flow, constructed as well as in constant flux. The Cynefin framework is one model to help our understanding of knowledge as a personal construct (...) achieved through sense making. Specific knowledge aspects temporarily reside in either one of four domains – the known, knowable, complex or chaotic, but new knowledge can only be created by challenging the known by moving it in and looping it through the other domains. Medical knowledge is simultaneously explicit and implicit with certain aspects already well known and easily transferable, and others that are not yet fully known and must still be learned. At the same time certain knowledge aspects are predominantly concerned with content, whereas others deal with context. Though in clinical care we may operate predominately in one knowledge domain, we also will operate some of the time in the others. Medical knowledge is inherently uncertain, and we require a context-driven flexible approach to knowledge discovery and application, in clinical practice as well as in health service planning. (shrink)

We are never illness or disease, but, rather, always their sum in the world of day-to-day experience. Disease and illness are not closed systems, but mutually constitutive and continuously interacting worlds. In the patient’s case it is always experience as well. Pain, sickness and death help make that particular experienced identity unavoidable, and at some level ultimately inaccessible to medicine’s changing understanding of disease and tools for managing it. Health—rather than cost containment, specific conditions, or technologies—should be the central focus (...) for health care and health-care reform. A compelling reason to focus on health comes from the observation that the prevalence of disease over the .. (shrink)

Background Metaphors are central to the human understanding of complex issues; through the immediate associations they evoke and frame problems and suggest solutions. Our suggestion of Music in the Park as a metaphor for health systems reform brings to the forefront the environmentally diverse but bounded spaces of health services that offer a variety of attractors within their confines, while pushing into the background organizational and economic concerns.Reflections Parks, like health services, are embedded in their local landscape, serving their communities, (...) but most importantly parks are public spaces, publically funded, ideally offering universal access and equity and to be shared by all who want to go there.Music, like health, is tangible, technical and scientific, yet ultimately experiential and based on meaning. While it encompasses a wide range of styles and approaches, music making requires as its most important skill active listening which brings with it to be ‘in the moment’, to take personal risks and to draw energy and inspiration from the participants. Hence ‘audiences’ are equally active participants because music only has meaning if it internally resonates with the listener and only can exist in what is a co-constructed experience.Conclusions Music in the Park is a metaphor for primary health care systems based on shared values of experts and unique local communities. Health professionals are players in this arena, who develop and practise the full range of their skills in response to individual and community needs and preferences. Their leadership works through inspiration and empowerment, making patients ‘co-producers’ of their own health and ‘co-shapers’ of their health services. (shrink)

BACKGROUND AND RATIONALE: Evidence based medicine is the present backbone of rational and objective, modern medical problem solving and is a meeting ground for quantitative and qualitative researchers alike as it culminates into applying the fruits of clinical research to the individual patient. A systematic enquiry into the evolving paradigms in EBM is a need of the hour. AIMS AND METHODS: A qualitative enquiry examining the impact of different methodologies in EBM and their role in generating meaning interpretable at individual (...) levels. RESULTS: Present day outcome based research deals less with patients as individuals than as populations. Evidence based medicine struggles to apply the fruits of population based research to individuals who are often not as predictable as linear quantitative research would like them to be. The present EBM literature neglects a lot of events it doesn't believe to be statistically significant and perhaps here is an area that needs to be improved on - it assumes that because associations are demonstrated between interventions and outcomes in RCTs/meta-analysis, these associations are linear and causal in the real world. While they may be demonstrated repeatedly in highly controlled environments, in the real 'uncontrolled' world of clinical practice with real people, their validity breaks down. CONCLUSIONS: One needs to make the EBM standard model patient-individual (a projection of collective patient event data) resemble the real human individual patient so that optimal EBM individual data that matches our query can be easily and quickly spotted from the dense jungle of information that has grown over the years. This hints at rethinking our entire research methodology and modifying it to suit the needs of the individual patient. (shrink)