{"id":16052,"date":"2012-04-05T14:08:00","date_gmt":"2012-04-05T13:08:00","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=16052"},"modified":"2012-04-05T14:08:00","modified_gmt":"2012-04-05T13:08:00","slug":"richard-smith-time-for-medicine-to-move-from-why-questions-to-how-questions","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2012\/04\/05\/richard-smith-time-for-medicine-to-move-from-why-questions-to-how-questions\/","title":{"rendered":"Richard Smith: Time for medicine to move from \u201cwhy questions\u201d to \u201chow questions\u201d"},"content":{"rendered":"

\"Richard<\/p>\n

A famous paper<\/a> 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\u2019s paper from Maria Isabel Ortega Velez, a Mexican nutritionist, at the University of Arizona\u2019s conference on global health leadership last week, and I wondered if these criticisms might apply to most of healthcare.<\/p>\n

Berg looked at United States funding of nutrition research and decided that 67% was concerned with \u201cwhy questions,\u201d 20% with \u201cwho and where questions,\u201d 11% with \u201cwhat questions,\u201d and less than 2% with \u201chow questions.\u201d Yet, argued Berg, it\u2019s \u201chow questions\u201d that make a real difference in the real world. Furthermore, \u201chow questions\u201d are usually culture and site specific, meaning that you usually can\u2019t generalise from one set of circumstances to another and to make a difference need to conduct studies in different places.<\/p>\n

As I heard about Berg\u2019s, several associated thoughts fired in my mind. The first was listening to Bill Clinton at a United Nation\u2019s meeting describing how when he was president he had been concerned with \u201cwhat and why\u201d questions but now realised that it was the \u201chow questions\u201d that made a real difference. Indeed, answers to \u201cwhat and why questions\u201d without answers to \u201chow questions\u201d may be largely useless.<\/p>\n

Then I thought of the criticism of the NHS that it scores \u201ceight out of ten for new ideas but three out of ten for implementation.\u201d An idea that isn\u2019t implemented is not just useless it\u2019s worse than useless. It\u2019s worse than useless because it breeds cynicism: \u201cwhy should we bother implementing this new idea because before we\u2019ve implemented it there\u2019ll be another new idea.\u201d<\/p>\n

Another association was with what I learnt at the Stanford Business School\u2014that devising a strategy is much easier than implementing it.<\/p>\n

How did we fall into the trap in health research of not paying enough attention to \u201chow questions\u201d? Perhaps it\u2019s the academic snobbery that thinks that scientists answer \u201cwhy questions,\u201d while engineers are concerned with \u201chow 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.<\/p>\n

People at the conference thought that medical journals might be to blame. \u201cIt\u2019s impossible,\u201d people said, \u201cto get papers that describe programmes of improvement published.\u201d 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\u2019s important, and journals then try to publish those studies.
\nThe criticism spurred me into one of my favourite riffs\u2014that whatever people do, whether it\u2019s 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 \u201chow questions.\u201d 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 \u201cit\u2019s especially important to publish accounts of failed programmes\u2014because we learn so much from failure.\u201d<\/p>\n

The current enthusiasm for \u201cimplementation research\u201d 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 \u201cgetting research into practice (GRIP)\u201d and knowledge transfer and that most funding is still directed to basic science.<\/p>\n

Is Berg\u2019s second criticism of nutritionists\u2014that their training is insufficiently operational\u2014also 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.<\/p>\n

So perhaps Berg\u2019s criticisms do apply to medicine and other sorts of healthcare. But what we need is not just a \u201cthinking out loud blog\u201d like this but a careful analysis that explores the case with data and makes recommendations for improvement, if, indeed, improvement is needed.<\/p>\n

RS was the editor of the <\/em>BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n

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