Personal views: Papa, Nicole, and the guideline industry
Authors: Paul Hodgkin
Journal: BMJ (1998)

In the television advertisement for Renault neither the suave Papa nor his sophisticated daughter, Nicole, are thinking much about cars. The advert does not mention guidelines, evidence, or outcomes, and fails to suggest any audit of the all important car buying cycle. Indeed cycles of any kind are the last thing on Nicole’s mind and Papa is clearly not interested in setting standards against which to measure performance. If a rational approach changed behaviour then our commercial breaks would surely be a lot duller. The lesson from Papa and Nicole is that people are more likely to act when they feel good, flattered, tantalised, powerful, sexy, or proud than when they are flooded with facts. 

This is not to put down facts. But in motivational terms a good story is worth a dozen facts. Medicine after all is structured around the endless (hi)stories that patients bring, and “I had a patient who” is almost always more memorable than “I read a paper that.” We run on stories not facts, because this is how, over past millenniums, we made sense of our worlds. Today that need to derive meaning through story, myth, and metaphor is played out on ward rounds and in the surgery, in casualty departments and the ambulance, and in the detailed, intuitive, sense making way in which we can take patients’ histories. Words and metaphors, however, are never neutral for they define the inner geography of our thoughts, easing the flow of some and damming others. Audit cycle, for example, conjures not just images of unending financial scrutiny but also the treadmill of other cycles—exercise, economic, menstrual. If the aim is to motivate then audit cycle is a copywriter’s nightmare. 

In a rapidly changing world the stories that we tell about change itself can become limiting steps in how fast we adapt. One such story is that doctors are rational, and therefore the key ingredient to coping with change is supplying good information. Another is that, since in medicine dysfunction equals sickness, poorly performing doctors are—literally—poorly. This metaphor sees guidelines as treatment, antibiotics for sick doctors, devised and administered by caring, kindly experts. It also leads us to see interventions to change behaviour as akin to drugs and so we end up doing randomised control trials to discover whether prompts and reminders are better than guidelines in changing clinician behaviour. If Papa and Nicole were doctors then clearly they would be randomising car use and comparing outcomes. 

The gulf between research and everyday practice, into which so many well meant guidelines are piously tossed, is also a gulf between different ways of understanding the world. For researchers (perhaps the most resistant of all breeds to change) the story is about a mythical search for truth structured around court room metaphors. Trials are conducted, cases studied, findings contested, evidence weighed, lines of inquiry followed, and judgment suspended until the hard facts are in. And like the Goddess of Justice holding her scales, researchers blind themselves to the outcome of their inquiries. The idealised output of the legal process—justice—is seen to be an end in itself and the legal profession is careful to distance itself from any consequences—such as punishment—which may flow from its deliberations. Similarly the research process has an idealised output—truth—which is wholly sufficient for most researchers. While this legalistic view of research as a way to unveil the truth has utility, it also constrains our ability to bridge the gap between research and practice. The “D” of research and development is, for most researchers, a runtish affair which they understandably expect others to deal with. Those concerned with development meanwhile are in thrall to the magnificence of research and consequently often feel that their task should not be doing development but researching it. 


How then to improve things? The answer is not simply to fall head over heels into an affair with Papa and Nicole, to expect advertising and marketing to succeed where guidelines, ownership, and opinion leaders have failed. And simply pointing out the inadequacies of language that development labours under, risks slipping into the cadence of the victim and blaming others. 


“Change as it occurs in the real world needs to be cultivated and nurtured”



So what are the metaphors and stories that will help us to develop, implement, and change? Change as it occurs in the real world needs to be cultivated and nurtured. It takes time to take root and become established. The local conditions and context are important—what works in one place may not work in another and preparing the soil is at least as important as disseminating the seed. Local barriers may need to be overcome or local variants developed. Here the metaphor is one of organic growth, of gardening. Time, nurture, good soil are all important. Once seen, the gardening metaphor opens other possibilities—resources are as necessary as fertilisers; gardens, being unmovable, require stewardship over the long term; and cultivated change needs to be able to endure and adapt to external pressures—storms, droughts, or the tendency for outside experts to demand that the existing plants are all grubbed out to make room for floribunda thatcherii, japonica blairensis, or for that matter a six lane, evidence based motorway. 

Beyond the individual clinician, successful change often demands that several organisations change in complementary ways. Achieving this requires the ability to tell stories that work at a system level and to construct coalitions that will support the change. A useful metaphor views the local health and social system as a series of autonomous nation states which collaborate and compete and which are composed of professional tribes speaking different dialects. Negotiation, different world views that are simultaneously both conflicting and valid, the need to actively translate between people even when they all seem to be speaking English, an appreciation that change always demands the judicious mixing of evidence, clinical judgment, and the art of the politically possible—all these understandings and metaphors go into successful change. 

Getting people to change is, quite properly, difficult and cannot be commanded by Papa and Nicole, by spin doctors, or by any other magic bullets. It is however probable that we can improve our ability to change, adapt, and develop clinical practice. If so then part of the answer lies in creating metaphors whose form and contour legitimates new ways to weave the gifts of scientific inquiry into the wonderful, complex messiness of the real world.  

I would like to thank Rosalind Eve, Ian Golton, James Munro, and Gill Musson for the debates which stimulated these thoughts.