Revelation of mindlines in the setting of crisis

Abstract

During the devastating early months of the unfolding COVID‐19 pandemic in New York, healthcare systems and clinicians dynamically adapted to drastically changing everyday practice despite having little guidance from formal research evidence in the face of a novel virus. Through new, silo‐breaking networks of communication, clinical teams transformed and synthesized provisional recommendations, rudimentary published research findings and numerous other sources of knowledge to address the immediate patient care needs they faced during the pandemic surge. These experiences illustrated underlying social processes that are always at play as clinicians integrate information from various sources, including research and published guidelines, with their own tacit knowledge to develop shared yet personal approaches to practice. In this article, we provide a narrative account of personal experience during the COVID‐19 surge. We draw on the concept of mindlines as developed by Gabbay and Le May as a conceptual framework for interpreting that experience from the standpoint of how early information from research and guidelines was drawn on and transformed in the course of day‐to‐day struggle with the crisis in New York City emergency rooms. Finally, briefly referencing the challenges to conventional models of healthcare knowledge creation and translation through research and guideline production posed by COVID‐19 crisis, we offer a provisional perspective on current and future developments.

Why all clinical guideline recommendations are ‘Conditional’

“…This was particularly evident during the first months of the pandemic when the severity of a still unfamiliar illness was at its height. 9 An historical mission of the Evidence-Based Medicine movement was to close the research-to-practice gap. In 1993, a widely cited article demonstrated a 10-year gap between the emergence of evidence supporting a specific intervention and its acceptance as standard care.…”

“…12,13 The tension between the lack of definitive research evidence and practitioners' need for guidance comes to the fore in times of healthcare crisis, as was seen during the recent pandemic. 9,14 The pandemic exposed two other impediments within the research-to-guideline-to-practice trajectory. The first relates to disparities in healthcare delivery and outcomes across racial, ethnic and socioeconomic divides.…”

“…Over this time, clinical practice may well change in ways that threaten the practical applicability of the recommendation. 9 The pandemic demonstrated that current technology has transformed the possible speed of research production, synthesis and dissemination. 11 Given the prospect of such an acceleration, the acceptability of a 5-or 10-year delay in producing a 'strong' clinically important recommendation is unlikely to hold.…”

“…Foremost was the difference between the timescale of change in clinical practice and that of the production, synthesis and incorporation into guideline recommendations of clinical research. This was particularly evident during the first months of the pandemic when the severity of a still unfamiliar illness was at its height 9 …”

“…The table illustrates the current existence of a similar time lag between the initial planning of a trial capable of definitively changing the evidence base underpinning a guideline recommendation and the incorporation of its findings into a revision (Table 1). Over this time, clinical practice may well change in ways that threaten the practical applicability of the recommendation 9 …”