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What is evidence? Reflections on the AMEE symposium, Vienna, August 2011
In this article, we present a summary of the discussion from the symposium on 'what is evidence', which took place at the AMEE conference in 2011. A panel of five academics and clinicians, plus the chair, considered the nature of evidence, in particular in relation to the 'evidence' in the best evidence medical education reviews. Evidence has multiple meanings depending on context and use, and this reflects the complex and often chaotic world in which we work and research. © 2012 Informa UK Ltd.
Introducing a nationally shared electronic patient record: Case study comparison of Scotland, England, Wales and Northern Ireland
Aim: To compare the experience of the four UK countries in introducing nationally accessible electronic summaries of patients' key medical details, intended for use in emergency and unscheduled care episodes, and generate transferable lessons for other countries. Method: Secondary analysis of data collected previously on all four schemes; cross-case comparison using a framework derived from diffusion of innovations theory. Main findings: Whilst all four programmes shared a similar vision, they differed widely in their strategy, budget, implementation plan, approach to clinical and public engagement and approach to evaluation and learning. They also differed, for various reasons, in stakeholder alignments, the nature and extent of resistance to the programme and the rate at which records were created. A nationally shared, widely accessible electronic record has powerful symbolic meaning; it may or may not be perceived as improving the quality and safety of care or (alternatively) as threatening patient confidentiality or the traditional role of the doctor or nurse. 'Hard' project management oriented to achieving specific milestones and deadlines sometimes appeared counterproductive when it cut across the 'softer' aspects of the programmes. Conclusion: When designing and implementing complex technologies with pervasive implications, policymakers must consider not only technical issues but also the personal, social and organisational aspects of the programme. A judicious blend of 'hard' and 'soft' management appears key to managing such programmes. © 2013 Elsevier Ireland Ltd.
Networks as systems: A case study of the World Health Organisation’s Global Health Workforce Alliance
Purpose: The purpose of this paper is to present a case study of the World Health Organization’s Global Healthcare Workforce Alliance (GHWA). Based on a commissioned evaluation of GHWA, it applies network theory and key concepts from systems thinking to explore network emergence, effectiveness, and evolution to over a ten-year period. The research was designed to provide high-level strategic guidance for further evolution of global governance in human resources for health (HRH). Design/methodology/approach: Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders, and academics. Data were analyzed thematically with reference to systems theory and Shiffman’s theory of network development. Findings: Five key lessons emerged: effective management and leadership are critical; networks need to balance “tight” and “loose” approaches to their structure and processes; an active communication strategy is key to create and maintain support; the goals, priorities, and membership must be carefully focused; and the network needs to support shared measurement of progress on agreed-upon goals. Shiffman’s middle-range network theory is a useful tool when guided by the principles of complex systems that illuminate dynamic situations and shifting interests as global alliances evolve. Research limitations/implications: This study was implemented at the end of the ten-year funding cycle. A more continuous evaluation throughout the term would have provided richer understanding of issues. Experience and perspectives at the country level were not assessed. Practical implications: Design and management of large, complex networks requires ongoing attention to key issues like leadership, and flexible structures and processes to accommodate the dynamic reality of these networks. Originality/value: This case study builds on growing interest in the role of networks to foster large-scale change. The particular value rests on the longitudinal perspective on the evolution of a large, complex global network, and the use of theory to guide understanding.
Adjuvant chemotherapy: An autoethnography
Adjuvant chemotherapy is given after surgery for early stage cancer. It aims to cure. Though potentially toxic, it has dramatically improved survival for some cancers. This paper offers an auto-ethnographic exploration of three kinds of strangeness that I encountered during a 12-week course of adjuvant chemotherapy for early breast cancer: the material strangeness of what was done to me; the lived-body strangeness of receiving chemotherapy (which makes people sick to make them well); and the existential strangeness of reconstructing my broken narrative. In a discussion, I consider four aspects of autoethnography of deep illness against which this account and its telling might be judged: ethnographic legitimacy (does it meet the standards of analytic social science?), autobiographical legitimacy (is it compelling as literature?), existential ethics (am I, the wounded storyteller, protected from harm?) and relational ethics (have I discharged my duties towards those implicated in the text and its interpretation?).