Denise Campbell-Scherer | Patient Care

I’ve always been interested in – how do we actually help people be healthier and, how do we take all of that systematically derived evidence that we have in the medical literature, and figure out how to synthesize that and integrate it into a person, into their lived world, in a way that helps them with their health- this translation from macro population type work into micro individual work. To me, actually, I’ve moved past personalized evidence-based medicine into something called context-based medicine so every person lives within their own context, their own social determinants of health, their own culture, their own family situation, their own work situation where, we would call, their own habitats and so, you really have to work with them to understand what matters to them, and what are the things that they need, and what do they want, with regards to their health. And then, how do we take all the rest of that evidence and figure out together what are the things that make sense for them so that they can have a healthier life.

DMacA: How can we research that complex picture?
DCS: There is a notion in the way that we have been doing it, where we adopt a reductionist lens, and where we try to study pieces and parts of it, and that gets us to a certain point. But sometimes we get so caught up in that research that we forget that there were fundamental assumptions that underpinned the work in the first place. I think that for doing what I’m talking about, we actually have to take a step back and embrace the fact that these things are complex and entangled, and adopt some different kinds of ways of knowing, some different paradigms, some different fundamental assumptions, some different methods to interrogate pieces of it.

DMacA: That’s so different from the reductionist way that we have done medicine in the past. How do we persuade universities and funding bodies to come around to that point of view?
DCS: I think, actually, life is going to try to persuade them because we’ve had a huge natural experiment with Covid, where it has brought into very sharp relief that what we’re doing now isn’t working for many people in our communities. So, there’s a fairly pressing need actually to- as everything is breaking- there’s an opportunity for us to rethink how to rebuild it and how to bring to bear what we know in different ways, to be able to find answers that are helpful. So, for example, one of the things that happens in reductionism is we end up very tribal, in our specific tribe of how we know things, the specific methods that we know, what we think is rigour, the assumptions that we make, the methods that we do, and the ways that we think things happen. We are not spending nearly enough time foundationally understanding the problem before we start to think about what solutions might be, and what studies might be. We’ve also spent the last hundred years systematically denigrating all of the fields of science which actually specialize in what I’m talking about namely, sociology (and) anthropology. These are disciplines that specialize in unpacking that complexity but we don’t talk together with them, we don’t work together with them, which is one of the reasons why at Alberta PLP, we have all kinds of different people with all kinds of different methods who’ve spent years honing their craft, working together to understand problems and to try to figure out solutions, together with front line users. And that’s what I think they have to do. I think we have to really spend a lot of time understanding the problem, and then figure out who are the people that need to be part of the study of the solutions.

DMacA: I’m very interested in your analogy that things are breaking because, when things are breaking, there’s also an opportunity to rebuild them. So, how can we reach, for example, research funding bodies- they focus very much on a particular type of study-journals focus on a particular type of publication- how can we bring people around to think in a different way?
DCS: You have to do it and then demonstrate to them why that’s helpful. You also have to change… Most of those structures in our society have developed around certain patterns of relationships and those patterns of relationships inherently work to preserve the dominant narrative in our society. So the people who are in the subdominant groups or, in the not dominant at all groups, don’t, aren’t part of those conversations. And so we’re starting to have more conversations about integrating people, families, patients, into conversations which is helpful. We’re still doing it too much on our own terms. When I say our own terms, I mean people that are in formal structures, rather than actually really getting out there into community and engaging on their terms. There’s a huge amount of wisdom and practical knowledge in the groups that we don’t normally talk to and we need to listen to them and how they would suggest we do it. I don’t know… there’s only a finite amount of time that you have on this earth to do work and you can spend it tilting out windmills and trying to change dominant formal structures, or you can spend it doing work, and I think it’s more useful to spend it doing work and then let the work stand for itself. And over time, if you have enough people doing that, you’re going to have a body of work which is actually very impactful and can help illuminate problems and shed lights on solutions in ways that some of the dominant paradigms cannot. But if you want to change formal systems you have to change the nature of the pattern of relationships like, who’s part of those. You have to take those voices that are not part of them, and you need to integrate them in, and I think there’s movements that way.

DMacA: I’m truly with you on that. It’s going to be very difficult to convince the real purists. How much success have you had in persuading funding bodies and journals to publish and to fund this type of work?
DCS: I don’t tend to fuss about it. I’ve never had more than 30% dedicated time for research. I see patients three days a week so and I’m just me and I’m not any great fancy researcher. So, I’m not going to be the person that convinces anybody. The issue is that you just choose to- you have to write the rules of the game that you’re going to play. You can choose to play those (other) games and you’ll be unsuccessful if you’re not in the dominant paradigm if you don’t play that game. So you have a choice. You can either dedicate your time towards try to solve problems and doing projects that you think are meaningful, or you can try to play the game to be successful by those other rules.

DMacA: If we bypass those structures the next stage is communicating the message. How do we communicate with the doctors out there that they need to think more broadly, how do we communicate with the patients to bring them in, how do we get those messages prioritized to policy and government?
DCS: That’s a very large question but I would submit to you that every practicing physician who spends their days seeing patients, who actually cares about the lived reality of the people that they serve, particularly generalists who have longitudinal relationships with other people, with humans, they all understand this.

Denise it’s been a real pleasure to explore all these aspects of, particularly family medicine, with you who has a particular interest in this and have studied it in depth. Denise, it’s always a pleasure. Thank you.