General Medical Practitioners Need to Be Aware of the Theories on Which Our Work Depend

Thank you Elizabeth Bayliss, Dan Munday, Richard Schmitt and Anton Kunzel for taking the trouble to submit a response about my paper on the theory of knowledge. I mostly agree with everything you say, but I would also like to clarify a few points.

Dan hit the nail on the head when he said that I am applying three theories which are ‘mutually incompatible’. I think of them as different universes of meaning. They are incompatible in the same way that sight, hearing and touch are incompatible. What I can’t agree with is that we should ‘fear’ this. Surely it is an opportunity to see the world in color rather than black and white. Do any of us go into a garden and say “what a terrible and confusing thing, I can, see, hear and feel – I must get rid of two of these senses?” I prefer to say that my stance challenges scientific orthodoxy that promotes reductionist, single-solution thinking. Instead we must learn how to describe truth as a process of crystallizing meaning from complementary insights, as well as triangulating data to find correct answers.

I agree with Richard that studying philosophy does not necessarily lead to a good place. But I didn’t say that it did. Instead I advocate paying attention to the breadth of things people are struggling to say, and purposefully using theories that help to do this in the best way. The dominant theory used in medicine does not help to do this. Consequently I, and other GPs, are morally obliged to explore philosophy to the extent that we find or develop more appropriate theories. The three fundamental theories I have described help me surface hidden and interconnected phenomena as well as consider presenting complaints, and also stimulate creative, often humorous, discussion about what it all means. I find this helpful in almost every consultation. By the way my name is Thomas, not Taylor.

I completely agree with Elizabeth that these are equal but different ways of looking at wholes, and complexity can always be found if you have a mind to look for it. But so can simplicity and complicated things always be found, if you care to look for them. I think that these three terms (simple, complicated and complex) make the same assumptions about the way the world works as the three paradigms I explore in my paper. But I did not, and would not, use the word ‘spectrum’ when describing them. Spectrum implies to me a continuous connection between different things. They are different kinds of light, when shone on the same situation reveal quite different things. I agree with your other comments, including N=1 studies.

Anton makes a point similar to Dan’s that the way I have portrayed critical theory and constructivism overly simplifies those traditions. I have to agree. And further - I have also simplified positivism. One reason for doing this is to relate to the ideas of Egon Guba who, in the Paradigm Dialog, distinguishes the different ontology, epistemology and methodology of three paradigms that carry these names. It was not my intention to fully describe these specific traditions, nor relate them to other traditions, but to use them as good examples of the strengths and weaknesses of the three different paradigms I have described.

What I don’t say in my paper is my belief that these three paradigms reflect three fundamentally different operations of a human mind, perhaps required to retain and develop a sense of self. I develop this idea in my book. I think that these paradigms are fundamental not because of what there is to find in the world, but because of how our minds construct ideas. At some point or other in all new ideas there is a need to acknowledge that there is a present known situation (positivism), to explore uncertainty (critical theory), and to play around to find new connections (constructivism). From time to time I examine a specific case that claims one of these three paradigmatic approaches. I find the other two approaches are always discernable. They are rarely highlighted and usually applied with appalling rigor - but they are there in some form. Consequently I am not a fan of any one particular research tradition in isolation, and advocate a sensitive combination of whatever is realistic and appropriate to the concerns of the moment.

Thank you for this opportunity to continue the debate.

Competing interests:   I wrote the original paper

Dr. Thomas provides a useful and explanatory framework to describe a process of care many primary care physicians have been using intuitively for years. (It may be safe to say that it is partly the inclination to think in these terms that causes many physicians to select a primary care specialty in the first place.) As Dr. Thomas points out, the combination of the three described ‘ways of knowing’ lend themselves well to the study and care of the complex patients (and complexities of patients) seen in primary care. Based on the multidimensional needs of patients and clinicians, he calls for less emphasis on quantitative (‘positivist’) methodology and more on ‘multimethod’ (incorporating critical theory and constructivist) approaches to research as well as practice.

The good news is that mixed-method research is alive and well and being practiced (not surprisingly) by primary care researchers in multiple areas of study. Several of these are nicely illustrated by Drs. Katerndahl and Crabtree in the current issue of Annals. (1) I see the above three methodologies as part of an iterative cycle in which quantitative investigations are informed from qualitative investigations and vice versa.

If these methodologies are seen as an iterative process, it may be a bit simplified to portray the ‘spectrum’ of positivism to critical theory to constructivism as analogous to theories that are simple, complicated and complex respectively. I would argue that they are different and equally important ways of looking at parts of the same whole and that the whole is always complex. Both critical theory and constructivism inform the choice of which areas to study with positivist methodology—critical theory by piquing our interest through meaningful anecdote, and constructivism by building consensus and agreement. Positivism uses a high -power lens to discern the ‘truth’ as we manipulate the variability of the process (under study) to approach zero. This ‘truth’ can then be re- analyzed through the low-powered lenses of qualitative methods to assess it’s usefulness in a meaningful context and adapted accordingly. All steps are required to understand the whole.

Most would agree that ‘best evidence’ in any given situation is not necessarily the applied result of meta-analyses of multiple low- variability positivist studies. ‘Best evidence’ probably results from the most strategic use of multiple methodologies to explore a question. Once upon a time, the ‘N of one clinical trial’ was considered best evidence. It could be argued that these rare studies used all three of the above theories: they were the application of very specific results (positivist) to an agreed-upon question (constructionist) in a relevant context (critical theory). The challenge then is to incrementally make it the norm to consider ‘truth’ in context for large and complex populations. Primary care researchers comfortable with mixed-method research are the ones to start this process.

(1) Katerndahl, D and Crabtree,B. Creating Innovative Research Designs: The 10-Year Methodological Think Tank Case Study. Annals of Family Medicine 4:443-449 (2006)

Competing interests:   None declared

Paul Thomas' reflections form a useful review of the complexities involved in health care and the need for a broad theoretical approach to aid practice.

However, I am concerned that he may be applying three theories which are mutually incompatible. Further from my reading of critical realism, I would question his definition of the term. I would in fact go further and suggest that all he is arguing for, in terms of developing a broad and flexible approach to practicing primary care, is consistent with critical realism.

Critical realists understand the world to be complex and that our knowledge of it is fallible (the transitive domain). However, they argue for the existence of reality external to our knowledge of it (the intransitive domain). They suggest that positivists and constructivists alike fall into the "epistemological fallacy" not recognising this distinction and by reducing ontology to epistemology.

As with critical theory, critical realism recognises an ontological depth which is necessary to appreciate relations of power and structural influences on human agency. This aspect is ignored in positivism, where explanations remain close to the surface e.g. in examining for empirical regularities in scientific explantion. However a critical realist approach allows for simple systems and the methods (such as RCTs) to test them (and critical realists get out of the way of buses!)

In addition, by understanding ontological depth and the influence of pespectives on knowledge, a creative potential is released. However this cocreativity is still grounded in a realist ontology. Different perspectives are relevant and potentially valuable in aiding understanding, but it is possible to judge between them (otherwise science is impossible), although such understanding remains fallible.

Those of us who want to widen the debate from the narrow positivist stance of EBM (I am not sure that it is even postpositivist)need to offer an alternative which is coherent and persuasive. I do not think that this will be achieved by adopting a realist ontology for one issue and a relativist one for another, although I agree, insights from constructivism can be extremely helpful. However, espousing a metatheoretical approach with a realist ontology and a relativist epistemology as in critical realism does provide a framework for developing theoretical and practical understanding of the complexity of primary health care.

Competing interests:   None declared

Dr. Taylor claims that knowing about positivism, critical theory and constructivism makes him a better practitioner. He is the best judge of that and I do not want to dispute his understanding of his own history.

But having been a practitioner of philosophy for 50 years I want to suggest some reasons for being sceptical of any general recommendation that many or all family physicians improve their practice by studying philosophy.

1. I have known many professional philsophers who acquired deserved fame in the profession for their subtle understanding of many controversies in ethics. A significant number of them were completely unreliable persons. The ethics they studied did not direct their actions.

2. We must remember the gap between knowing and doing. Knowing that smoking causes lung cancer does not always suffice to motivate persons to give up smoking. In similar ways a sophisticated understanding of the importance of contexts in understanding persons may not always suffice to make practitioners truly understanding in their examination room.

3. Philosophers like to refer to their views as "theories" without always admitting that philosophical theories are different from scientific ones in at least one important respect: some scientific theories, at least, rest on a large body of carefully tested evidence. Not so philosophical theories--they are claims to truth that rest on sometimes ingenious argumentation, that always has equally ingenious opponents. Philosophical theories are, at best, a series of tentative answers to interesting, but often also quite esotheric questions. The life of philosophical theories is in controversies--sometimes enormously interesting, at other times excessively esotheric.

Knowing any philosophical theory is not like knowing a theory in physics, for instance. Knowing a philosophical theory is being able to participate in the arguments philosophers have with one another.

There seems to me to be no obvious connection between, say, being able to argue on a professional level about the claim that only scientifically verifiable statements have meaning and being a physicvian whose grounding in contemporary evidenced based medicine is exemplary.

Richard Schmitt

Competing interests:   None declared