Revised March 12, adding Hacking’s “structure” passage.
This is #2 in a new series “Proposing a new science of patient engagement,” using the landmark 1962 book The Structure of Scientific Revolutions by Thomas Kuhn as its framework. If you haven’t read the first entry, please do, including its dozens of comments, which have links to valuable ideas and resources.
In an upcoming post I’ll lay out briefly why it seems this project is needed. I say “seems” intentionally; this must be a shared exploration. As I said in #1,
My goal is … to have science move forward methodically in its thinking. Maybe we need a new science – a new way of understanding what needs to be measured and optimized – or maybe we don’t. I just ask that we examine the evidence together.
This post will lay out, briefly, the stages Structure describes for the progression of science. I’m doing this first because that framework provides the context for my assertion that we have a problem – a scientific problem in the field of medicine – that may require formally (and rigorously) changing our conception of who is capable of what in the patient-clinician relationship.
As you’ll see, a shared conception of how things work is exactly what a paradigm involves.
Kuhn’s view of the progression of a science
From Ian Hacking’s widely praised introduction to the 50th anniversary edition of Structure:
Structure and revolution are rightly put up front in the book’s title. Kuhn thought not only that there are scientific revolutions but also that they have a structure. …
Here is the sequence: (1) normal science…; (2) puzzle-solving; (3) paradigm…; (4) anomaly… (5) crisis and (6) revolution, establishing a new paradigm.
Going a bit deeper on some of Kuhn’s core concepts:
- Pre-paradigm: until a field comes up with an agreed view of how things work, practitioners are groping in various unrelated parts of the field.
- In electricity, before Ben Franklin figured it out, some people were fascinated with electricity’s flow, and thought it must be a fluid that they could bottle to sell in stores; others were fascinated with the attractive and repulsive forces; there was no coherent model.
- (Note: later on, Kuhn said “pre-paradigm” was a mistake, but for our purposes that probably won’t matter.)
- Paradigm: When someone figures out a view that seems to explain everything, and everyone agrees, you have a paradigm, and at last you have a scientific field: all practitioners agree what’s important, what needs to be measured, etc. That makes possible the next step:
- Normal science, which Kuhn said involves “puzzle solving” – picking interesting questions and figuring them out.
- Note that until there’s a paradigm – an agreed view of how things work and what’s important – you can’t have a question that everyone in the field agrees is interesting, right?? That’s how important the paradigm is to a scientific field: it’s an existential question.
- Anomaly: This is where it gets juicy: in the previous post’s video I said “Then there comes a time in every science, sooner or later, where you get a bunch of what he calls ‘anomalies’ that force you to say, ‘How could this be happening if the world works the way we think it does??'”
- Discovery: From Section VI, “Anomaly and the Emergence of Scientific Discoveries”: (I’m putting this in color because it’s the core of this project and we’ll return to it later.)
Discovery commences with the awareness of anomaly, i.e., with the recognition that nature has somehow violated the paradigm-induced expectations that govern normal science. …
It then continues with a more or less extended exploration of the area of anomaly.
And it closes only when the paradigm theory has been adjusted so that the anomalous has become the expected.
- Crisis happens when no matter how hard you try to bend the current view, it just can’t adapt. (Some anomalies can be explained by tweaking the paradigm, but others can’t.) The situation becomes scientifically intolerable, and if that ain’t a crisis, I don’t know what is.
- Revolution is the most severe stage. (I’m not predicting a revolution; as I said, such things only arise when the larger community says so.)
- Revolution doesn’t always happen, but when it does, it can get ugly, like all revolutions.
- He calls it a revolution because the old and the new can no longer exist, cannot share the “palace,” so to speak. (My words, not his.) Reputations must be rebuilt, textbooks must be rewritten, etc.
In an upcoming post
the next post I’ll spell out what problem (what “puzzle,” in his terms) our current paradigm seems to face … what anomalies seem to exist, that lead to our being unable to manage patient engagement successfully – or, I will assert, to even agree on what it is. That in turn will lead to the question, “What current belief, if any, is holding the field back?”
Next in the series: #3: The role of unexplained observations