Hi!
An interesting discussion has developed over the last
few days between myself, Rakesh and Carmel about the possible uses of some variant
of BNIM in fostering (by way of IT) user-driven health care reform.
As you will see from the most recent messages (just
below), we’ve agreed that other people on the BNIM e-list might be interested in
the discussions and also might wish to contribute.
This discussion is obviously only at an early stage, but
the notion of ‘doing BNIM interviews by computer’ is philosophically interesting
and the question of how some variant could be ‘automated’ is also worth thinking
about.
So: do join in if you’re interested. I’m putting Rakesh,
Carmel and Kevin
on the e-list, so if you do join in, any message to the list will automatically
go to them as well!
Best wishes. Tom.
P.S. Almost forgot.
As with all such accumulative messages, you need to read from the bottom of this
email upwards back to the top.
----------------------------------------------------------------------------------
FROM Rakesh
Thanks Tom,
Very interesting insights. It would be great if you copy
this to your list and even better if you make us members of your mailing
list.
Would be nice to hear how others would approach this.
Yes as Carmel
pointed out this discussion is partly brainstorming for the NDRC grant proposal.
We have our own list but right now it has been silent and most of the
discussions have been between the three of us.
Would be great if you could meet Carmel and we could have
the advantage of your expertise and of your team.
rakesh
On 10/22/08, [log in to unmask]
<[log in to unmask]>
wrote:
Tom
Thanks for your comments. Sure I would be happy
to extend our email discussion to a wider group. I don't know if you know the
back ground to our discussion.
I am writing a grant proposal to the NDRC (www.ndrc.ie). As it happens, my husband Kevin Smith has moved
to NDRC from Canada in July this year. I am
writing a translational research grant to the current ndrc call - see www.ndrc.ie/howitworks.html so that I may hopefully move here
also. I am an academic family physician and health services researcher and we
have a wide network of interested co-investigators in Australia, Canada, India, ireland.... We are very keen to move
beyond reductionist models that plague our discipline and health services
reform. We have a strong interest in complex adaptive systems.... etc. I am
currently in Dublin for 3 weeks 'holiday' before
going back to Canada. I do drop in in London quiet regularly. We
are also looking for academic and business partner for our
proposal.
Carmel
On Oct 22, 2008 8:12am, tom wengraf <[log in to unmask]> wrote:
Dear Carmel and
Rakesh,
I very much like your 22-10-08 account
of your PhD (which I've still to read!) and of
'sense-making', Carmel. Especially the notion of 'understanding situatedness': this connects and amplifies
helpfully the notion of 'situated subjectivity' (HiSST2)
which I suggest in the Guide to BNIM as a default concept for psycho-societal studies in general and for BNIM-using research
in particular. I would only add that 'understanding
situated subjectivity' by way of "connections (which can be
among people, places, and events)" can also be about
understanding 'disconnections and disjunctions" and I would
modify "among people" to read "within
and among people".
As regards your point, Rakesh, where
you write "s/he may be able to scale up/build
upon her own
story over a period of time", I think
this might happen.
However, I think it
might just as easily not happen and the person might keep repeating what in the
Guide I refer to as their "official version/Public
Relations subsession 1 story" more or less over and over again. I have a Dead Sea / water saturated with salt/ model of
'defended subjectivity' in which the person avoids more
detail, or uncomfortable thoughts, or whatever by staying
at a certain level at or near the surface. They need
determined and/or skilfull 'nudging downwards' against that
propensity to drift up and surfacewards. So I would say that having a
subsession 1 and 2 is much more likely to produce the Whole
Narrative +
Particular PINs (the goal of BNIM
interviewing) than is a long series (whole lifetime?) of
repeated subsession 1s, even given that experience of a whole series of encountering other people's subsession 1s as
well!
Any objections if I copy this discussion to
the BNIM e-list? I think it
would be interesting to them
and they might well have good ideas to offer?
----------------------------------------------
FROM Carmel
Rakesh/Tom
I think that the BNIM discussion has
potential in our proposed work and it is primarily at the level of a formative
pattern recognition research tool.
My phd identified 3 interwoven patient
narratives - the illness/health experience (internal); the treatment narrative
(internal and external), the life trajectory school, work, social networks
internal and external).
My theoretical and operational approach to
patient narratives today is that of sense making in the following
context.
"Chronicity" implies
ongoing asynchronous and heterogeneous journeys of individuals through disease,
illness and care encompassing health promotion, preventative care, diagnosis,
self management, disease management and control, treatment and
palliation.1
"IT interventions in
chronic care need to be flexible, adaptive and above all useful and empowering
to patients, caregivers, clinicians and learners (users) at the point of care."
2
Sensemaking is the ability or
attempt to make sense of an ambiguous situation. More exactly, sensemaking is
the process of creating situational
awareness and understanding in
situations of high complexity or uncertainty in order to make decisions. It is
"a motivated, continuous effort to understand connections (which can be among
people, places, and events) in order to anticipate their trajectories and act
effectively" (Klein et al, 2006a).
Carmel
FROM: Rakesh
For a robust operational clinical
system we need to develop pattern recognition programs that are informed and
monitored by BNIM type processes in the background.
2008/10/21 Rakesh Biswas <[log in to unmask]>
I agree it would be definitely more useful to have the
sub session 2 to extract the narrative out of the person (I too have experienced
this difficulty of not being able to get a proper story in one session).
However my idea was that with multiple sessions where
the individual gets feedback from others and also reviews her own story s/he may
be able to scale up/build upon her own story over a period of time (which means
a life time since s/he gets hooked).
I would also like to hear what Carmel thinks about this.
Great to keep this discussion alive.
rakesh
-----------------------------------------------------------------------------------------
OK. The advantages of
your proposal is that it is very straightforward. The disadvantage is that
there is no sub-session 2. Our experience is that most people need the
'pushing for PINs' in subsession 2 for the narratives to become very felt,
very rich, and very informative……. The question would be, how to do it. The
subsession 1 'initial poured out heart/narrative' is in BNIM that which sets
the agenda for further questioning. Sometimes it can be very rich; more often
it isn't. I think the best thing would be to run a pilot in the way you
suggest but perhaps have a sub-sample of that pilot with some arrangement for
(a phone) subsession 2. You would get some idea of the difference then and
decide whether you do or don't need the default mode to include a sub-session
2. If you thought that it might worth trying to mak the default mode one of
both subsession 1 and subsession 2, you could explore whether this was
technically possible – as per my note (1) in my original email
below.
All
right...this is how I believe it may work (the feedback part comes at the
end):
Just
imagine your basic mobile handset into which you simply dial a number (toll
free) and pour out your heart into it (particularly when you have the
time...waiting in a que to see a physician or sulking after a tiff with
spouse/partner).
All this
data that you entered (mostly consisting of the story of your life) could now
be transcribed into a web based platform equipped with web 2.0 tools that
immediately scoop out similar stories based on your story (you can be given
the option of entering the keyword tags yourself even on the voice mail box or
let the web software decide like google does for its gmail ads).
Eventually you get addicted to entering
voice data through your mobile because you immediately get to hear stories
that are similar to yours and yet have different insights to
offer.
rakesh
-------------------------------------------------------------------------------
On
10/21/08, tom wengraf <[log in to unmask]>
wrote:
Dear
Rakesh,
I have only had time
to scan the two articles you sent me superficially, but I found them really
interesting. I look forward to reading them properly later.
A couple of thoughts
as to how BNIM might enter in.
1) The interview. A
key function of BNIM is to ask in subsession 1 for 'whole Story' of some
period of time defined by the researcher. Then in subsession 2, the
interviewer picks out certain items mentioned in subsession 1 and asks for
'more detailed story' about them, often pushing several times (over several
rounds) for such 'more story'. The formulations of the questioning for
subsession 2 are rather standard. However the selection of items for asking
such 'more story' questioning are not well-formalised. The Guide discusses
selection crtiteria and criteria for 'following up or not' in subsession 2.
The giving of 'further questioning feedback on initial responses', how might
this be done?
2) Interpretation.
The default BNIM model for 'interpretation' is quite complex and
time-consuming, and I doubt whether you would find it relevant or useful. It
lends itself to use in a very small number of cases, not a large N. Of course,
you might at some point want to use a small theory-generating sub-sample. The
'giving of feedback on the entered data' that you mention. How is this/would
this be done?
Anyway, if you have
time to look at the relevant parts of the Guide, I would lov e to hear about any
thoughts you may come to have about BNIM's usability.
Good to
hear from you. I hope you may have received Carmel's thesis by now. She has reached
Dublin.
I have
attached some preliminary models we devised earlier and are still building
upon to collect patient narratives that would constitute valuable information
flow which would in turn drive work flow in health care.
As you
pointed out the best way to utilize the BNIM method would be to utilize some
of its principles in generating a user driven narrative preferably through a
mobile phone interface. I believe It would be possible to drive the whole
interview process in bits and pieces through an IVR (interactive voice
recording) system. This collected voice data in turn could be
transcribed/translated on to a text based web interface where thematic field
analysis could be done using available qualitative analysis software.
I believe
the greatest driver to this whole process would be the feedback individual
users receive on their own entered data and this would be essentially
asynchronous yet meaningful (again derived from extracting themes from the
patient user's entered data).
The
problem with a chat/message room mode is that it would become synchronous and
could introduce a lot of unwarranted noise into the
system.
Look
forward to building on this discussion.
rakesh
-----------------------------------------------------
I'm afraid that – due
to a cookie problem – I couldn't follow your prequel suggestion. Could you
send some material in some other way, perhaps – like a WORD or PDF. I would be
really interested in knowing about your project.
I would be very
interested to see how an experiment with BNIM with 'internet users' worked
out. As far vas I know, nobody has tried this out and this would be a 'first'.
What are my first thoughts about it?
BNIM is designed to
provoke and to interpret improvised narrative interviews. It is
therefore more likely to work well with telephone interviews than with written
interviews, since writing allows for more deliberation and correction.
It may be that there is a way in which the deletions and rewritings of the
chat room can themselves be recorded. This would be
ideal.
Consequently I think
you would get better results if you worked on the Internet with a message room
or chat room mode. This would to some extent at least preserve the
observed improvisation aspect that is central to
BNIM.
As I say, I don't
think anybody has explored yet what can be done with BNIM interviewing via the
Internet. If you do experiment with this, I would love to be involved in
one way or another.
Thanks Tom,
I did download this earlier but good to have the recent
update.
Carmel is on her way to
Dublin from Ottawa at the moment and will reply soon.
We are particularly interested in utilizing the BNIM in
a large population sample of internet users who would be contributing to their
personal health records by telling the story of their lives from which different
health care themes effecting mutiple dimensions of a patient's illness will be
extracted.
Do let us know how feasible do you think this would be
as a transformative health care model.
Here is a prequel to the operational model:
http://www3.interscience.wiley.com/journal/118001064/abstract?CRETRY=1&SRETRY=0
Do let me know if you would like to read
more.
warm regards,
rakesh
From: Rakesh Biswas [mailto:[log in to unmask]]
Sent: 17 October 2008
12:40
To: Carmel
Martin
Cc: [log in to unmask]; Kip
Jones
Subject:
Re: interviewing for lived experience BNIM method
Hi
Carmel
A few
quotes: Hunter (in Mishler 1995) reminded us
that medicine is filled with stories and is, in fact, dependent on narrative, is
essentially case-based knowledge and practice and that clinical judgement is
"fundamentally interpretative"
(1995:112-113).
The BNIM
from what I understand after reading this is essentially a free flow of
narrative from the patient's end followed by multiple interpretations by a team
(perhaps a health care network? like we have been
contemplating/conceptualizing). At the moment the health care network has
consistently interrupted a free flow of the patient's story and this is what is
paramount in salvaging at the moment.
I guess a
free flow might even best come out of a patient web user's keyboard or
any other input device that may encourage expression without interruption
(rather than a human interviewer as is the present BNIM method).
I am also
copying this to Tom and Kip who are prominent practitioners of the BNIM method
for their comments (if any) on our comments/interpretations.
rakesh
--------------------------------------------------------------------------------------------------
On
10/17/08, Carmel Martin <[log in to unmask]> wrote:
Rakesh
yes - thanks for this, it looks good for an
update.
Note that that is what many of us are doing every day in general
practice.
my phd was heavily qualitative as well as quantitative - the care
of chronic illness in general practice. chris peterson - new to you - works
closely with the chronic illness alliance in australia
http://www.chronicillness.org.au/ and the health issues
centre
my phd worked with chronic illness self-help groups across the
1990's
glad that we are finally getting to translate some of these types of
work into influencing health care and systems through IT.
carmel
2008/10/16
Rakesh Biswas <[log in to unmask]>
