Richard Smith: Time for medicine to move from “why questions” to “how questions”

Richard Smith

A famous paper published in 1993 by Alan Berg of the World Bank asked why the world had done poorly at feeding everybody. Berg had two answers: nutritionists do the wrong kind of research and train people in the wrong way. I heard of Berg’s paper from Maria Isabel Ortega Velez, a Mexican nutritionist, at the University of Arizona’s conference on global health leadership last week, and I wondered if these criticisms might apply to most of healthcare.

Berg looked at United States funding of nutrition research and decided that 67% was concerned with “why questions,” 20% with “who and where questions,” 11% with “what questions,” and less than 2% with “how questions.” Yet, argued Berg, it’s “how questions” that make a real difference in the real world. Furthermore, “how questions” are usually culture and site specific, meaning that you usually can’t generalise from one set of circumstances to another and to make a difference need to conduct studies in different places.

As I heard about Berg’s, several associated thoughts fired in my mind. The first was listening to Bill Clinton at a United Nation’s meeting describing how when he was president he had been concerned with “what and why” questions but now realised that it was the “how questions” that made a real difference. Indeed, answers to “what and why questions” without answers to “how questions” may be largely useless.

Then I thought of the criticism of the NHS that it scores “eight out of ten for new ideas but three out of ten for implementation.” An idea that isn’t implemented is not just useless it’s worse than useless. It’s worse than useless because it breeds cynicism: “why should we bother implementing this new idea because before we’ve implemented it there’ll be another new idea.”

Another association was with what I learnt at the Stanford Business School—that devising a strategy is much easier than implementing it.

How did we fall into the trap in health research of not paying enough attention to “how questions”? Perhaps it’s the academic snobbery that thinks that scientists answer “why questions,” while engineers are concerned with “how questions?” In other words, one is the superior basic science and the other applied science. Although healthcare must be an applied science, we aspire to the grandeur of basic science.

People at the conference thought that medical journals might be to blame. “It’s impossible,” people said, “to get papers that describe programmes of improvement published.” I like to think that few outdo me in criticising journals, but this seemed to be a case of shooting the messenger. Academics and medical schools decide what’s important, and journals then try to publish those studies.
The criticism spurred me into one of my favourite riffs—that whatever people do, whether it’s molecular biology, a randomised trial, or a programme of improvement, it ought to be published. We are used to the idea that to do a research trial and not publish it is misconduct, but for me the same applies to improvement programmes, studies answering “how questions.” In reality most of these programmes are not even written up let alone published. Unlike academics, people who conduct these programmes are not rewarded for publishing. Indeed, the time to write up programmes and the hassle to get them published are disincentives. The climax of my riff is to say “it’s especially important to publish accounts of failed programmes—because we learn so much from failure.”

The current enthusiasm for “implementation research” may mean that those funding research have recognised the problem identified by Berg. But I note that implementation research may have had previous incarnations as “getting research into practice (GRIP)” and knowledge transfer and that most funding is still directed to basic science.

Is Berg’s second criticism of nutritionists—that their training is insufficiently operational—also true of healthcare? I can speak only for medicine, and it seems to me that medical training includes too much theory, too many lectures, and too little operational learning. I hope that things are better now, but as a young doctor I remember having to perform for real procedures like putting up drips and attempting to resuscitate patients without ever having received instruction. I think of a professor from a prestigious medical school telling me how students boast about being able to graduate without touching a patient. And Nigel Crisp, former chief executive of the NHS in England, argues in his book on global health that too many health workers are trained for professions rather than tasks.

So perhaps Berg’s criticisms do apply to medicine and other sorts of healthcare. But what we need is not just a “thinking out loud blog” like this but a careful analysis that explores the case with data and makes recommendations for improvement, if, indeed, improvement is needed.

RS was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.