CONTROL OF ANTIBIOTIC RESISTANCE – FORMS OF KNOWLEDGE, STANDARDS AND TECHNOLOGIES IN GENERAL PRACTICE
- STUDYING CLINICAL GUIDELINES’ TRANSLATION FROM SCIENCE PRACTICES TO ITS ENACTMENT IN CLINICAL PRACTICES AND THEIR RELEVANCE TO RATIONAL ANTIBIOTIC USE
Background
As a consequence of the increasing awareness of the necessity of a targeted effort to combat antimicrobial resistance in humans and animals, the intersectional science collaboration UC-Care was established in 2013 made possible by a 4-year grant from the University of Copenhagen. The UC-Care research is based on the fundamental assumption, that a holistic and multidisciplinary approach is needed if we are to find a solution to the major challenges that our current use of antibiotics in humans and animals has lead to. It is acknowledged that drug discovery alone is not sufficient to mitigate the spread of resistant bacteria. By contrast, if our aim is to effectively inhibit the development of the resistant bacteria, that threatens our health, then it is crucial to increase our focus on the socio-material practises in which the enactment and use of already existing forms of antibiotics takes place.
Today, 90% of all prescriptions of an antibiotic are prescribed in general medical practice (GMP). Among these, the majority is prescribed to patients suffering from an infection to which antibiotics are without any effect. Therefore, it seems of paramount importance to explore the governance of antibiotics in the complex situated practices of the clinical consultation. In relation to this, it is recognized that both care and treatment of patients to a large extent is dependent upon dialogue between local actors, not only practitioners, but also users, including both those to whom the medicine is prescribed, relatives and other stakeholders. In practice, medical activities are governed by a complex set of standards for both disease and health. These are based on various ways to organize knowledge, different technologies, that renders practices and objects possible and subtle forms of interaction together with specific traditions providing implicit approaches to understanding and relating to humans, bodies, emotions and everyday life. In addition to this, a great deal of general medical practice is carried out with reference to knowledge derived from and generated in research practices. Take for instance diagnostic systems, different technologies of evaluation, point of care tests and, which is of particular concern to this project, clinical protocols. At the same time, the competent general practitioner must be able to assume a patient-centred perspective foregrounding the users own standards, experiences and conduct of everyday life. Once again, it is expected, that all of these standards and forms of knowledge are reflected upon and balanced with a distinct responsibility relating to general public health.
It is therefore a basic assumption of this project, that a more thorough understanding of these processes is needed if we are to improve the ways in which researchers, industries and doctors interact with users to develop more advisable standards for prescribing antibiotics.
Aims
The project will be focusing on different forms of knowledge, standards and technologies, the practical encounter, and the affected bodies, as these are perceived, negotiated and enacted in practice by both professionals and patients, as part of their conduct of everyday life. Through qualitative descriptions and analysis, the aim is to explore how knowledge and standards implied in clinical protocols are translated from research practices to general medical practices and in which ways these are enacted in and interact with other forms of knowledge and standards prevailing in the actual clinical encounter with the individual patient, his embodiment, self-understanding and everyday life.
In collaboration with The Danish College of General Practitioners (DSAM) the intention is to study two concurrent developments:
1) Governance of antibiotics in general medical encounters targeted at diagnostics and treatment of urinary and respiratory infections, framed as a process of negotiation between professionals and users, partially mediated by scientific knowledge and standards implied in clinical protocols.
2) Having acknowledged that the process of implementing clinical protocols up until now have been neglected in favour of the process of elaborating clinical protocols, DSAM is at present working on a new strategy for implementation. Therefore, the intention is to be in continuous dialogue to benefit from the considerations that results from each of the project’s work.
By raising questions on how implementation of clinical protocols is thought, it is the hope of the present project to be able to support development of more suitable ways of implementing clinical protocols. This is expected to be of importance for the fulfilment of the entire goal of UC-Care, since future clinical protocols, resulting from the work conducted inside UC-Care, will be implemented in accordance with this new strategy of implementation.
Research questions
Approach and Methods
The overall approach is derived from science and technology studies (STS), where epistemological and ontological issues are investigated empirically, in a ‘praxeology’ or practice research that relates micro-studies with broad cultural-historical tendencies (cf. Bowker & Star, 1999; Latour, 2005; Mol, 2002), and especially takes up the aspect of subjectivity (cf. Brown & Stenner, 2009; Mattingly, 2010; Nissen, 2012; Zizek, 2006). The project uses qualitative methods as developed in psychology and medical anthropology. In order to achieve a useful empirical focus, the researchers first establish collaborations with practitioners and follow them into encounters with users. These encounters are observed and described. These data then serve as the platform for further interviews with practitioners (stimulated recall), as well as further observations. Both before and during the time of the data collection, researchers from the SUBSTANce center participate in UC-Care, WP6 and DSAM meetings in order to sharpen the empirical focus.
Organization
The project is designed as a post-doc project, headed by post.doc., M.sc. Psych. Mads Bank, as part of the Section for Health Service Research, Department of Public Health, University of Copenhagen. The work group collaborates with the research center SUBSTANce – Subjects and Standards (http://substance.au.dk), headed by professor Morten Nissen. In addition, two master students have been recruited as assistants.
Publications
Findings from the project will be published as 2 scientific articles (e.g. in Subjectivity, Social Studies of Science, Sociology of Health and Illness), as well as in one chapter in the planned Danish-language anthology.
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