The term “best practices” in education always gives me trouble. Normally I wince, but let it pass. So I was delighted when Dr. Jerome Groopman shared the same reaction regarding “best practices” in medicine in a recent essay in The New York Review of Books. (He is Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston.)
The rhetoric around education reform has long borrowed from the world of business. But it has also latched onto the reforms in medicine. I’ve argued that neither was comparable to education since both are easier to measure along lines that do not involve political or ideological biases. Defining good health does not divide Blues from Reds, although how to pay for it and who decides what surely does. (I was always puzzled how whole language vs. phonics became a right vs. left issue).
Groopman reminds us that what constitutes “best practice” in medicine is controversial, even when it comes to the “basics” of curing people or preventing illness. Evidence (and best practice) shifts rapidly. Doctors (looking at the same data) offer conflicting opinions and large-scale studies conducted to “settle it” produce results that get overturned 10 years later. The knowledge needed, he argues, may well best be situated in the contextual knowledge that rests between doctor and patient—plus easy access to second opinions by both parties. You have to read it all to realize how comparable the arguments are about the weight we should give “The Data” in either field in making decisions about “Patient X.”
Groopman presents the case from two perspectives. On one side are Richard Thaler and Cass Sunstein. Sunstein is a professor of law and Thaler of behavioral science, respectively. They seem roughly to be taking Groopman’s position regarding “best practice.” (He describes it as a sort of “nudge” approach, in the service of “libertarian paternalism.”) On the other side is Peter Orszag, director of the federal Office of Management and Budget. Orszag believes that behavioral economics should guide the delivery of health care; he doesn’t trust doctors and health administrators to do what is “best” unless there are clear and unambiguous mandates along with “aggressive promulgation of standards and changes in financial and other incentives.” (Sound familiar?) Groopman describes his own work in the field and how often his own research created ‘best practice’ that turned into bad practice.
There is, Groopman contends, “a growing awareness….that past efforts to standardize and broadly mandate ‘best practices’ were scientifically misconceived…” What was to one research scientists a “no-brainer” was to another far more complex. “The care of patients is complex, and choices about treatment involve different tradeoffs. That the uncertainties can be erased by mandates from experts is a misconceived panacea, a ‘focusing illusion.”
What Groopman suggests is not that we cease engaging in scientific research and the sharing of information, but that we remain open to the importance in medicine of interpreting the complexities of the data closer to the field of practice. Creating institutions—hospitals and departments of medicine that keep abreast, demand collegiality and good documentation of practice is what is needed to keep medicine both honest and forward-looking. In a field such as education, whose essential underlying purpose includes far more unsettled issues of purpose, including something as elusive as “character,” not to mention its default position in favor of democracy with its peculiar respect for individual judgment, the Groopman argument holds up even better. See also this dissertation writing page.
If we demand only practices that meet the “evidence-based” authorities, the critical experimental work by educators with deviant ideas will never get off the ground. Where will the ideas critical for our long-term future come from if we mandate a single path? When we think about schooling as a “race” against adversaries, with “test scores” as the only acceptable evidence, we forget that the human species is in for a long-distance run. Had we not been allowed to experiment with small schools of choice in East Harlem, the “small schools movement” might not have happened. (Which, for all the faulty implementation of the idea, is still, I believe, a powerful tool.)
The tricky role of “trust” must be confronted head-on. In “In Schools We Trust,” written some nine years ago, I tried to think “trust” through around one school—Mission Hill. We have much work to do to discover ways to improve education that do not further undermine trust—without which democracy and even learning the “basics” depend.