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PromotingTranslationalResearchinMedicinethroughDeliberation

GordonR.MitchellandKathleenM.McTigue•

Paperpresentedatthe“Justification,Reason,andAction"Conference

inHonorofProfessorDavidZarefsky

NorthwesternUniversity

Evanston,IL

May29&30,2009

•GordonR.MitchellisAssociateProfessorofCommunicationandDirectoroftheWilliamPitt

DebatingUnionattheUniversityofPittsburgh.KathleenM.McTigueisAssistantProfessorofMedicineandEpidemiologyUniversityofPittsburgh.Portionsofthisresearchwerepresentedearlieratthe12thWakeForestArgumentationConferenceinVenice,Italy,June16‐18,2008.

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PromotingTranslationalResearchinMedicinethroughDeliberation

Abstract

Withtheprojectofdrawinguponprinciplesandconceptualtoolsfromargumentation

theorytoinformthematuringEvidence‐BasedMedicine(EBM)movementwell

underway,thetimeisripetoconsiderthepotentialofdeliberationtoelucidate

researchpathwaysintranslationalmedicine.Whilemany"benchtop‐to‐bedside"

researchpathwayshavebeendevelopedin"TypeI"translationalmedicine,vehiclesto

facilitate"TypeII"translationthatconvertscientificdataintoclinicalandcommunity

interventionsdesignedtoimprovethehealthofhumanpopulationshavereceivedless

attention.Astheselatterformsoftranslationalmedicineimplicatesocial,political,

economicandculturalfactors,theyrequire"integrative"researchstrategiesthatblend

insightsfrommultiplefieldsofstudy.Thisessayconsidershowargumentation

theory'sepistemologicalflexibility,audienceattentiveness,andheuristicqualities

yieldconceptualtoolsandprincipleswithpotentialtofosterinter‐disciplinary

exchange,helpresearchteamspercolatecogentarguments,andcultivatephysician‐

citizenship,therebypromotingTypeIItranslationalmedicine.

KEYWORDS:translationalresearch,argumentation,rhetoric,Isocrates,

hypothesis‐testing,evidence‐basedmedicine,EBM,publichealth.

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PromotingTranslationalResearchinMedicinethroughDeliberation

TheprecariousstateoftheUShealthcaresystemhasstimulatedmuch

reflectiononbetterwaystodeliverhigh‐quality,lower‐costcaretomorepeople.

Medicalscience,inparticular,hasbeenlookedtoasapotentialsourceofsolutionsin

thisregard.Indeed,thenation'sstrongmedicalresearchinfrastructurehasan

impressivetrackrecordofachievementinbasicscience.Butinrawform,scientific

dataconferlittlebenefittophysicians,patients,andtaxpayers.Toachievefullpractical

impact,scientificfindingsmustbeconverted,consistentlyandsustainably,into

concreteinterventionsthatimprovehealthoutcomes.

Seeinganeedforimprovementinthischallengeofconvertinggrowthof

scientificknowledgeintobetterqualityhealthcare,theUSmedicalestablishmenthas

developedmajorinitiativesdesignedtopromoteevidence‐basedmedicine(EBM)and

translationalresearch.Bothinitiativesfeaturesignificantpointsofintersectionwith

communicationscholarship.InthecaseofEBM,ateamofCanadianscholarshas

launchedasignificantresearchprogramdesignedtorefinetheEBMapproachusing

argumentationtheory,whileleadersinthenascentfieldoftranslationalresearch

increasinglycallforinter‐disciplinaryresearchteamspursuingtranslationalmedicine

tointegrateexpertiseincommunication.WiththeU.S.healthcaresysteminastateof

flux,thetimeisripeforcommunicationscholarstosurveythelandscapeandassess

howtheymightplayaproductiveroleinthisimportantconversation.

Evidence‐BasedMedicine

As"thehardartofsoftscience,"1medicinefacesadifficultjugglingact.Its

practitionersareexpectedtomakedecisionssystematically,yetalsoadaptjudgments

tofitlocalexigencies.Formuchofhumanhistory,themedicalprofessionsoughtto

strikeabalancebetweenthesetwinobjectiveswitha"practicemakesperfect"

approach.Physicianstrainedtogether,withthepresumptionthatthroughmultiple

1MilosJenicek,"TheHardArtofSoftScience:Evidence‐BasedMedicine,ReasonedMedicine,or

both?,"JournalofEvaluationinClinicalPractice,12(2006):410.

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repetitionofjointcasemanagement,seniordoctors'practicalwisdomandclinical

insightwouldtransfertotheirmorejuniorcolleagues.Forthemostpart,thisdirect

instructionmodelhasservedmedicinewell.Yetthedevelopmentofmodernscience,

especiallybranchesofinquirydirectlyrelatedtomedicinesuchasbiologyand

chemistry,haspromptedcallsfor"evidence‐based"approachesthatwouldbring

scientificfindingstobearmoredirectlyonmedicalpractice.

Theincorporationofobjectivepopulation‐basedevidenceintowesternclinical

carewasinitiallyadvocatedinprominentfashionbyPierreLouis(1787‐1872),a

Parisianphysicianwhoderivedclinicalinsightfromsystematicpatientobservations.2

Hispioneeringworkaddressedthebenefitsandharmsofthethenstandardpracticeof

blood‐letting,byexaminingthefeaturesandoutcomesofgroupsofpatients.3Louis’

“numericalmethod”attractednumerousfollowers.Someofhisstudentsformedthe

SocietyforMedicalObservationinParis,othersfoundedtheStatisticalSocietyin

London,andanothergrouphelpedestablishtheAmericanStatisticalsociety.4Yet

Louis'approachremainedcontroversialanddidnotgainamajorfootholdinthe

teachingandpracticeofmedicine.5

PublicinvestmentinhealthcareresearchafterWorldWarIIresultedinasurge

inbasicsciencethateventuallyyieldedmyriadrandomizedcontrolledtrials,butstill

leftagapbetweenevidenceandpractice.Asaresult,bytheearly1990s,therewasa

pressingneedtounderstandwhichpotentialinterventionswork,andhowwell.6

Steppingintothisbreach,agroupofresearchersatMcMasterUniversitylaunchedin

2D.L.Sackett,Evidence‐BasedMedicine:HowtoPracticeandTeachEBM,2ded.(Edinburgh:

ChurchillLivingstone,2000);M.BestandD.Neuhauser,"PierreCharlesAlexandreLouis:MasteroftheSpiritofMathematicalClinicalScience,"QualityandSafetyinHealthCare,14(December2005):462‐464;andP.K.Rangachari,"Evidence‐BasedMedicine:OldFrenchWinewithaNewCanadianLabel?,"JournaloftheRoyalSocietyofMedicine,90(May1997):280‐284.

3Rangachari,"OldFrenchWine";andAlfredoMorabia,"InDefenseofPierreLouiswhoPioneeredtheEpidemiologicalApproachtoGoodMedicine,"JournalofClinicalEpidemiology,62(January2009):1‐5.

4BestandNeuhauser,"MasteroftheSpirit."5Rangachari,"OldFrenchWine."6A.Levin,"TheCochraneCollaboration,"AnnalsofInternalMedicine,135(2001):309‐312.

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1992aresearchprogramunderthebanner"evidence‐basedmedicine."7Concurrently,

agroupofBritishresearchersformedtheCochraneCollaboration,“toprepare,

maintainanddisseminatesystematicreviewsoftheeffectsofhealthcare

interventions.”8Thenewfieldofevidence‐basedmedicine(EBM)gainedtraction

rapidly,restructuringhowclinicaldecision‐makingistaughtandpracticedacross

diversedisciplinaryandgeographicboundaries.9

ArecentsearchoftheNationalLibraryofMedicine(NLM)database,focusing

on“Evidence‐BasedMedicine”asasubjectheadingorkeyword,showsatotalof

35,205articlesmeetingthosesearchcriteria,withadramaticriseinpublishedarticles

intheyearsbetween1990and2008(seeTable1).Duringthissametimeperiod,

evidence‐basedmedicinehasbeenwidelyacceptedasanimportantpartofmedical

education,witheducationalcurriculadevelopedthroughouttheprocessofmedical

training.10TheCommonProgramRequirementsfortheAmericanCollegeforGraduate

MedicalEducation(ACGME),whichgovernsUSresidencyprograms,includesthe

statement:“residentsmustdemonstratetheabilitytoinvestigateandevaluatetheir

careofpatients,toappraiseandassimilatescientificevidence,andtocontinuously

improvepatientcarebasedonconstantself‐evaluationandlife‐longlearning.”11

[InsertTable1abouthere]

7GordonGuyattfortheEvidence‐BasedMedicineWorkingGroup,"Evidence‐BasedMedicine:ANewApproachtoTeachingPracticeofMedicine,"JournaloftheAmericanMedicalAssociation,268(1992):2420‐2425.

8A.Levin,"TheCochraneCollaboration,"AnnalsofInternalMedicine,135(2001):309‐312.9J.F.King,"AShortHistoryofEvidence‐BasedObstetricCare,BestPractice&ResearchClinical

Obstetrics&Gynaecology,19(February2005):3‐14;andH.L.Kennedy,"TheImportanceofRandomizedClinicalTrialsandEvidence‐BasedMedicine:AClinician'sPerspective,"ClinicalCardiology,18(May1999):471‐480.

10MeenakshyK.AiyerandJosephineL.Dorsch,"TheTransformationofanEBMCurriculum:A10‐yearExperience,"MedicalTeacher,30(2008):377‐383;ColinP.WestandFurmanS.McDonald,"EvaluationofaLongitudinalMedicalSchoolEvidence‐BasedMedicineCurriculum:APilotStudy,"JournalofGeneralInternalMedicine,23(July2008);andPhillippDahm,GlennM.Preminger,CharlesD.Scales,Jr.,SusanF.Fesperman,LawrenceL.Yeung,andMarcS.Cohen,"Evidence‐BasedMedicineTraininginResidency:ASurveyofUrologyProgrammeDirectors,"BritishJournalofUrology,103(February2009):290‐293.

11ACGMEBoard,"CommonProgramRequirements:GeneralCompetencies,"ACGMEOutcomeProject,http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf(accessedMay24,2009).

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TheMcMastergrouphasworkedextensivelytopromoteevidence‐based

medicineasakeytoolforclinicaldecision‐making,bypublishingbooks12and

conveningworkshopsonteachingaboutevidence‐basedclinicalpractice.13Because

theMcMasterapproachisconsideredthestandardinanumberofteachinghospitals,

wedrawfromitheretobrieflydescribehowEBMmaybeintegratedwithclinical

practice.14

Attheoutset,itisimportanttorealizethatevidence‐baseddecision‐making

encompassesthreekeyelements:thebestresearchevidence;clinicalexpertise;and

patientvalues.MuchofthepublicdiscussionaroundEBMhasfocusedonthefirstof

theseelements,whichcomprisesabroadarrayofdataspanningbasicscience

research,patient‐centeredclinicaltrials,evaluationofdiagnostictestsorprognostic

markers,andthesafetyoftherapeutic,rehabilitativeandpreventiveregimens.Inthe

EBMapproach,thesedatashouldbeintegratedwiththeclinician’spriorexperiences

andclinicalskills,whichallowhim/hertoidentifyapatient’shealthstate,risksand

benefitsofpotentialinterventions,andpersonalvalues.Thosevalues–theunique

preferences,concernsandexpectationsthatapatientbringstoeachclinicalencounter

–comprisethethirdkeycomponentofanevidence‐basedclinicaldecision.

Onceaclinicalproblemisidentified,theEBMapproachrecommendsthatthe

clinicianuseittodevelopananswerableclinicalquestion,thentrackdownthebest

evidencewithwhichtoanswerthatquestion.Justfindingdataisinsufficient–the

clinicianshouldalsocriticallyappraisetheevidence,assessingitsvalidity,impact,and

applicabilitytothepatientinneed.Thecriticallyappraisedevidenceisthenintegrated

withthephysician’sclinicalexpertiseandthepatient’spersonalhealthstate,values,

andcircumstances.Finallythephysicianshouldreflectontheprocess,andconsider

possiblewaystoimproveitthenexttimeasimilarquestionarises.

12Sackett,Evidence‐BasedMedicine.13McMasterUniversity,"HowtoTeachEvidence‐BasedClinicalPracticeWorkshop,"

http://ebm.mcmaster.ca/.AccessedMay24,2009.14ThefollowingdescriptionofEBMiscondensedfromSackett'sEvidence‐BasedMedicine,the

authoritativesourceonthisissue.

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AnimportantaspectofEBMistherecommendationthatcliniciansformally

considerthequalityoftheevidencethattheyareincorporatingintotheirdecision‐

makingprocess.Cliniciansareaskedtoevaluateboththetypeofevidence(basedon

studydesign)andthemethodsusedtocarryoutthespecificstudy.Oncerelevantdata

aresortedbytype,cliniciansusetheEBMhierarchyofevidenceasakeytoassign

relativeweightstothevarioustypesofdata(seeFigure1).Forexample,for

therapeuticstudies,expertopinionandbackgroundinformationonatopicare

consideredthelowestqualityofevidence.Nextarecasereportsregardingasingle

patient,thenstrongerobservationalstudydesigns,andinthemorepreferredcategory,

randomizedcontrolledtrials(soplacedastherandomizationstepisdesignedto

removepotentialareasofbias).Finally,systematicreviewsormeta‐analysesassessing

theentireliteratureonaclinicaltopicareconsideredoptimalinthechoiceofclinical

evidence,andthusappearatthetopoftheEBMevidencehierarchy.

Itisessentialtonotethatstudytypeisnottheonlyfeatureinvolvedinthe

assessmentofevidencequalityinEBM–cliniciansarealsoaskedtoevaluatethe

specificfeaturesofanindividualstudy(e.g.,itsinternalvalidity),aswellasassessthe

degreetowhichitappliestotheirpatient(e.g.,itsexternalvalidity).Furthermore,the

appropriatestudydesigndifferswiththetypeofclinicalquestion.Forexample,ifthe

clinicianfacesaquestionondiagnosisandscreening,thepreferredevidenceisdrawn

fromcross‐sectionalstudiescomparinganewtestwiththebest‐establishedprior

testingapproach.

[InsertFigure1abouthere]

Argument‐BasedMedicine

TheintegrationofEBMintoclinicalpracticeduringthe1990sprompted

substantialdiscussioninmedicalcirclesandbeyond,muchofitconcerningwhat

CanadiansociologistHarleyDickinsoncallsthe"EBMparadox."15Accordingto

15HarleyD.Dickinson,"Evidence‐BasedDecision‐Making:AnArgumentativeApproach,"

InternationalJournalofMedicalInformatics,51(1998):73.

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Dickinson,thisparadoxarisesfromatensionbetweentwokeytenetsofEBM:1)The

normativeprivilegingofRCTsandsystematicreviewsasevidencegoldstandards;2)

Theprinciplethataphysician'sclinicalexpertiseservesastheultimateauthorityfor

decidingwhetherandhowpracticeguidelinesshouldbeappliedtomatchan

individualpatient'sclinicalstate.If,asDickinsonreasons,"informationderivedfrom

RCTsandsystematicreviewsofRCTsisthe'goldstandard'formakingdecisionsabout

therapythenitisparadoxicaltoalsomaintainthatsuchdatamustalwaysbe

subordinatedtoclinicalexpertiseinclinicaltreatmentdecisions."16

Resolutionofthisparadoxdemandstheoreticalfinesse,anaccountofthe

clinicaldecision‐makingprocessthatacknowledgesthesaliencebothofscientific

evidenceandclinicalexpertise,aswellasheuristicsfordetermininghowtheseinputs

fittogether,especiallyinappliedcontextswheretheyappeartobeintension.Inabid

todevelopsuchheuristics,Dickinsonturnstoargumentationtheory,drawingfromthe

workofBritishphilosopherStephenToulmin,Canadianargumentationscholar

DouglasWaltonandGermancriticaltheoristJürgenHabermas.Notingthatkeyaspects

ofclinicaldecision‐makingmirrorthetypesofreasoningprominentinargumentative

"informallogic,"DickinsonseesopportunitiesheretoanswersomeofEBM's

detractorsbydrawingfromargumentationtheory.

Inparticular,DickinsonsuggeststhatToulmin'sstructuralmodelofargument

providesvaluableheuristicresourcesfortheoristsandpractitionersseekinguseful

answerstotheEBMparadox.Formallogichasonlylimitedutilityinthisregard,

becausediagnosticdecision‐makingtendsnotconformtothehypothetico‐deductiveor

nomological‐deductivemodelsofreasoning.17However,bychartingtheclinical

decision‐makingprocessintermsofToulmin'sdata‐warrant‐claimstructure,18it

becomespossibletodistinguishandidentify"warrant‐using"data(clinical

16Dickinson,"Evidence‐BasedDecision‐Making,"73.17Onthispoint,DickinsoncitesV.Patel,D.A.EvansandD.R.Kaufman,"ACognitiveFramework

forDoctor‐PatientInteraction,"inCognitiveScienceinMedicine:BiomedicalModeling,ed.D.A.EvansandV.L.Patel(Cambridge,MA:MITPress,1989),257‐312.

18StephenToulmin'sTheUsesofArgument(Cambridge:CambridgeUniversityPress,1958)developsamodelforunderstandingargumentpatternsthatresistreductionintothecategoriesofformallogic;seealsoWayneE.Brockriede&DouglasEhninger,"ToulminonArgument:AnInterpretationandApplication,"QuarterlyJournalofSpeech,46(1960):44–53.

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examinations,interviewsanddiagnostictests)from"warrant‐establishing"data

(systematicresearchintotherapeuticefficacyofstandardmedicaltreatments).19In

Toulmin'stheory,therelativesoundnessofargumentscanbeassessedbydetermining

onwhatbasistheirwarrantslinksupportingdatatooverarchingclaims.Whenapplied

toclinicaldecision‐making,DickinsonsaysthisinsightyieldspurchaseontheEBM

paradox,byprovidingforpractitionersheuristicsthatfacilitatesoundabductive

reasoning.

AroundthetimethatDickinson'sarticleappeared,otherconversationswere

takingplaceinCanadathatwouldeventuallystrengthenEBM'slinkwith

argumentationtheory.Oneparticularlyconsequential,cross‐disciplinaryconnection

occurredatMcMasterUniversityinHamilton,Ontario—thewidelyrecognizedsiteof

EBM'sNorthAmericanbirthplaceandlocationwhereMcMasterprofessorsMilos

JenicekandDavidHitchockdevelopedacollaborativeresearchprogram.Ina2005

textbook,Evidence‐BasedPractice:LogicandCriticalThinkinginMedicine(published

bytheAmericanMedicalAssociation),Jenicek,professorofclinicalepidemiologyand

biostatistics,andHitchcock,professorofphilosophy,developedafull‐blowntreatment

ofEBMasanargumentativeprocess.20

TwointroductorystatementspunctuateEvidence‐BasedPractice's

interdisciplinarycharacter.Ina"physician'sforeword,"Harvardprofessorof

ambulatorycareSuzanneFletchersaysthatwithpublicationofthetext,"clinicians,as

wellasmedicalresearchersandhealthplanners,canunderstandbettertheworldsof

'criticalthinking'and'evidence‐basedmedicine'andhowtheyrelatetoclassic

philosophicalthought."21Ina"philosopher'sforeword,"renownedinformallogician

RobertEnnisapplaudsJenicekandHitchcockfortheir"pioneeringdetailedwork,"

singlingitoutasoneofafewrareworksthatpursue"explicitapplication"ofcritical

thinking"inafieldofstudyorpractice."22

19Dickinson,"Evidence‐BasedDecision‐Making,"78.20MilosJenicekandDavidL.Hitchcock,Evidence‐BasedPractice:LogicandCriticalThinkingin

Medicine(Chicago:AMAPress,2005).21SuzanneW.Fletcher,"Physician'sForeword,"inEvidence‐BasedPractice,xv.22RobertH.Ennis,"Philosopher'sForeword,"inEvidence‐BasedPractice,xiii.

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TheemphasisoncriticalthinkinginEvidence‐BasedPracticereflectsthemark

oftheCanadianschoolofargumentationscholarship,ofwhichHitchcockisa

prominentmember.23Canadianinformallogiciansincorporatethepedagogical

conceptofcriticalthinkingtoelucidatehowstudentsandcriticscanoperationalize

Toulmin'sessentialinsightsaboutargumentasanexerciseinmovingfromdatato

claimsusingwarrants.Evidence‐BasedPracticecatalogsnumerousinstanceswhere

modesofmedicalpractice,suchasdoctor‐patientcommunicationandtherenderingof

expertcourtroomtestimony,matchupwithpatternsofreasoningininformallogic.For

eachoftheseinstances,JenicekandHitchcockexplicatehowconceptsandtermsfrom

theirrespectivefieldsoverlap,thenusethesepointsofoverlaptogeneratecritical

thinkingheuristicsadaptedspecificallytothemedicalcontext.

Forinstance,JenicekandHitchcockpointoutthatmedicaldiagnosesand

treatmentdecisionsinvolvedistincttypesofhumanreasoning.Adiagnosisbeginswith

"premises,"suchas"theresultsofaclinicalexamination"andleadstoa"conclusion

thatthepatientdoesordoesnothavethediseaseunderconsideration."Likewise,"the

conclusionofthediagnosticprocessbecomesapremiseleadingtotheconclusionthat

thepatientshouldorshouldnotbetreated,andbywhichtherapeuticmaneuver,such

asdrugs,surgery,supportandsoon."24Sincethispatternofreasoningclosely

resemblesacategoricalsyllogism,JenicekandHitchcockproposethatitcanbe

profitablyunderstood,practiced,andtaughtusingtheoreticalconceptssuchasthe

Toulminmodelofargument.

GiventhestrongtraditioninCanadianinformallogicscholarshipofanalyzing

argumentationbyfocusingonfallacies,orerrorsinreasoning,itisnotsurprisingthat

Evidence‐BasedPracticehighlightshowphysiciansattemptingtoexecutethe

principlesofEBMcanmakemistakesinreasoning.Forexample,JenicekandHitchcock

warnagainsttheposthocfallacy(orfallacyoffalsecause)indiagnosticcontexts(e.g.

23SeeHitchcock'seditedvolume,TheUsesofArgument:ProceedingsofaConferenceat

McMasterUniversity,18‐21May2005(Hamilton:OntarioSocietyfortheStudyofArgumentation,2005);aswellashis“TheSignificanceofInformalLogicforPhilosophy,"publishedintheCanadianjournalInformalLogic,20(2000):129‐138.

24JenicekandHitchcock,Evidence‐BasedPractice,196.

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"anembolismwascausedbyatransoceanicflight,becausethevictimwaswellon

boardingtheplane").25Theyalsopointouthowtheadignorantiamfallacy(some

statementmustbetruebecausethereisnoevidencetodisproveit)canproduce

medicaltreatmenterrors(e.g.regardinguntestedalternativemedicines,"nobodyhas

provedtheydonotwork,sotheymust!").26InEvidence‐BasedPractice,Jenicekand

Hitchcockframetheirpreliminaryworkinthisareabyobserving,"amorecomplete

compilationofanumericallyopen‐endedlistoffallaciesinmedicalreasoningmuststill

beworkedup,"ataskthatJenicekwouldpursueinhisnextmajormonograph.27

In2008,Jenicekpublishedthesole‐authored,Fallacy‐FreeReasoningin

Medicine:ImprovingCommunicationandDecisionMakinginResearchandPractice.28

Onceagain,thisbookusedtheToulminmodelofargumentasastartingpointfor

explainingmedicalreasoningfromthevantagepointofinformallogic.Butratherthan

isolatingargumentativeerrorsbyrelyingexclusivelyonthecatalogofclassical

Aristotelianfallacies(theso‐called"standardmodel"),Jenicektheorizeda

smorgasbordoffallacieswithclevernamesneverbeforefeaturedprominentlyin

argumentationliterature.29Forexample,the"threemenmakeatiger"fallacyoccurs"if

anunfoundedpremiseismentionedandrepeatedbymanyindividuals,thepremise

willbeerroneouslyacceptedasthetruth."Jenicekdrawsthenameforthisfallacynot

fromancientGreekandLatin(asinthestandardmodel),butfromaChineseproverb

aboutreportsofaloosetigercirculatinginKingWei'scapitalcity.Accordingtothe

legend,KingWeiremainsskepticalofthefirsttworeportsabouttheloosetiger.But

whenathirdcivilianechoesthesamereport,thekingchangeshismind(erroneously,

asitturnsout).Jenicekseesparallelmistakesinmedicalreasoning,suchas:"Somany

differentauthorsrecommendthebenefitsofrepeatedenemasthatyoushould

25JenicekandHitchcock,Evidence‐BasedPractice,55.26JenicekandHitchcock,Evidence‐BasedPractice,245.27JenicekandHitchcock,Evidence‐BasedPractice,56.28MilosJenicek,Fallacy‐FreeReasoninginMedicine:ImprovingCommunicationandDecision

MakinginResearchandPractice(Chicago:AMAPress,2008).29Onthe"standardmodel"ofargumentativefallacies,seeC.L.Hamblin,Fallacies(London,

Meuthen,1970.

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considerthisproceduretoo."30ForJenicek,suchabreakdownincriticalthinking

entails"anyuncriticalandnonsystematicreviewoftheliteratureorotherinformation

proclaimedastruthbecauseofitsrepetitionanditsindiscriminateuses."31Jenicek

elaboratesawholemenuofrelated,colorfullynamedfallaciesinthisvein,suchasthe

"if‐by‐whiskey"fallacy,32the"slothfulinduction"fallacy,33andthe"vaguenumberism"

fallacy."34

Inintroductorycomments,Jenicek'ssharesahopeisthathismonographwill

contributeto"reducingerrorsinmedicine"bypromoting"fallacy‐freeclinicaland

communitymedicinereasoninganddecisionmakinginmedicalcareandhealthcare

policysettings."35ThisaimcoincideswithcoretenetsofEBM,since"eventhebest

evidenceintheworldofevidence‐basedmedicinemaybewastedinfallacious

argumentation."36

Jenicekunderscoresthispointbycoininganewterm(withhelpfrominternist

G.Altbbaa),"argument‐basedmedicine,"todescribeanapproachtoEBMmade

possiblebyintegrationofargumentationtheoryintomodesofmedicalreasoning.

AccordingtoJenicek,argument‐basedmedicineis"theresearchandpracticeof

30Jenicek,Fallacy‐FreeReasoninginMedicine,124.31Jenicek,Fallacy‐FreeReasoninginMedicine,124.32If‐by‐whiskeyfallacy:"Presentationofanissueinsuchawaythattherecipientofthe

messagecanagreewithbothsidesoftheissue.ThistypeofopinionpresentationwasoriginallyusedtoreflectuponwhetherthelegalizationofwhiskeyconsumptionmightbeconsideredduringtheProhibitionyearsintheUnitedStates."Medicalcounterpart:"Ifweconsidermorphineasanaddictivesubstanceleadingtodependency,financialandsocialdisruptionoflife,toxicity,andoverdosing,wemustbanitfromuse.Ifwefinditsuseimportantasananalgesicofspecialinterestinthetreatmentofmyocardialinfarction,pulmonaryedema,dyspnea,andotherproblemsinend‐of‐lifecare,wemustsupportitsavailabilityanduse"(Jenicek,Fallacy‐FreeReasoninginMedicine,58).

33Slothfulinductionfallacy:"Theproperconclusionisdenieddespiteevidencetothecontrary."Medicalcounterpart:"Thepatientwehavejustseenforhisfifthworkaccidentandensuinginjuriesinsiststhatthisisjustacoincidence(company'sfault,hishealth,andsoforth)andnothisfault"(Jenicek,Fallacy‐FreeReasoninginMedicine,101).

34Vaguenumberismfallacy:"Offeringvagueandoftenmeaninglessandexaggeratingquantificationsinsteadofrealdata."Medicalcounterpart:"Arepresentativeofapharmaceuticalcompanyvisitingahospitalsays,'Wehaveworkedonthedevelopmentofthisnewdrugforanumberofyears.Wealsoassignedanunusualnumberofresearcherstothisproject.Theresult,thenewdrugIambringingtoyourattentiontoday,isimportantforanumberofreasons"(Jenicek,Fallacy‐FreeReasoninginMedicine,103).

35Jenicek,Fallacy‐FreeReasoninginMedicine,x,xix.36Jenicek,Fallacy‐FreeReasoninginMedicine,105.

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medicineinwhichunderstandinganddecisionsinpatientandpopulationcareare

supportedbyandbasedonflawlessargumentsusingthebestresearchandpractice

evidenceandexperienceasargumentationbuildingblocksinastructured,fallacy‐free

mannerofargumentation."37

AnecdotalevidencesuggeststhatJenicek'sindexofnewfallaciesrepresentsa

realadvanceincriticalthinkingpedagogy.UndergraduatestudentsattheUniversityof

Pittsburghstudyingargumentrespondedwithgreatenthusiasmwhenpresentedwith

someofJenicek'splayfullynamedfallacies.Theyretainedmoreinformationaboutthe

errorsinreasoningunderlyingeachfallacy,andwereabletoapplysuchtheoretical

insightmorereadilytopracticalarguments.Whetherargument‐basedmedicinecan

deliveronitspromisetoimprovehealthoutcomesinthemedicalcontexthingeson

severalfactors,includingwhethermedicalprofessionalsexhibitasimilardegreeof

enthusiasmforlearningfallacies,whether"fallacyfree"reasoningactuallyreduces

harmfulmedicalerrors,andtheextenttowhichreductioninmedicalerrorsresultsin

betteroverallqualitycare.

TheprevioustwosectionselucidatedtheoriginsanddynamicsofEBM,and

detailedhowargumentationtheoryhasbeendeployedinanefforttorefinetheEBM

approach.Ontheirown,thesedevelopmentsshouldpiquetheinterestof

argumentationscholars,asEBMhasquicklyemergedasadominantparadigmfor

medicaldecision‐makinginundertwodecades.Thefactthattwobook‐lengthstudies

blendingEBMandargumentationhavebeenpublishedinthepastfouryearsspeaksto

thetheoreticalfecundityofargumentationasaresearchprogramwithstrongpotential

fortrans‐disciplinarycross‐fertilization.Mighttherebeadditionalopportunitiesfor

similarsortsofcollaborationinthisresearcharea?Inlookingforpossibilities,the

emergentprogramof"translationalresearch"inmedicineisagoodplacetostart.

TranslationalResearch

Whileevidence‐basedmedicinemadestridestowardclosingthegapbetween

basicscienceresearchandclinicalpractice,theconsiderabledepthofthatgapbecame

37Jenicek,Fallacy‐FreeReasoninginMedicine,141.

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apparentthroughoutthe1990s.In2003,theNationalInstitutesofHealthannounced

itsRoadmapInitiative,withagoalof“defin[ing]acompelling,limitedsetofpriorities

thatcanbeactedonandareessentialtoaccelerateprogressacrossthespectrumofthe

institutemissions.”38TheRoadmapincludesthreethemes:

(1)NewPathwaystoDiscovery,addressingtheneedtounderstand

complexbiologicalsystems;

(2)ResearchTeamsoftheFuture,recognizingtheneedforresearchers

tomovebeyondtheirindividualdisciplinesandexplorenew

organizationalmodelsforteamscience;and

(3)ReengineeringtheClinicalResearchEnterprise,focusingonrecasting

theentiresystemofUSclinicalresearch.

Asapartofthisthirdtheme,theNIHmadetherelativelynewfieldof

translationalresearchapriority,allocatingresourcestopromotetraininganddevelop

asupportstructureforthefield.Thefieldof"translationalmedicine"focusesonthe

taskofconvertingbasicscientificdataintopracticalapplicationsthatimprovehuman

healthinappliedsettings.39

TheNIHdefinestranslationalresearchbyisolatingtwoconveyorbeltsdesigned

tobringbasicsciencetoappliedcontexts:“Oneistheprocessofapplyingdiscoveries

generatedduringresearchinthelaboratory,andinpreclinicalstudies,tothe

developmentoftrialsandstudiesinhumans.Thesecondareaoftranslationconcerns

researchaimedatenhancingtheadoptionofbestpracticesinthecommunity.Cost‐

effectivenessofpreventionandtreatmentstrategiesisalsoanimportantpartof

translationalscience.”40

TheInstituteofMedicinehasdescribedtwo“translationalblocks”intheclinical

researchenterprise,whichalignwiththetwoareasoftranslation(Type1or"T1,"and

Type2or"T2")describedintheNIHdefinition.Thefirstoftheseblocks(T1)hinders

38EliasZerhouni,"Medicine:TheNIHRoadmap,"Science,302,(2003):63‐72.39SeeM.E.J.Lean,J.L.Hoek,R.M.Elliot,andG.Schofield,"TranslationalResearch:From

Evidence‐BasedMedicinetoSustainableSolutionsforPublicHealthProblems,"BritishMedicalJournal,337(2008):863

40UnitedStatesNationalInstitutesofHealth,2009Glossary&AcronymList,http://grants.nih.gov/grants/glossary.htm#T(accessedMay24,2009).

15

thetransferofnewunderstandingsofdiseasemechanismsgainedinthelaboratory

intothedevelopmentofnewmethodsfordiagnosis,therapyandpreventionandtheir

firsttestinginhumans.Thesecond(T2),blocksthetranslationofresultsfromclinical

studiesintoeverydayclinicalpracticeandhealthdecisionmaking.Dr.StephenWoolf

ofVirginiaCommonwealthUniversityarguesthatwhilethesecondblockhasbeen

historicallyoverlookeditisactuallyofcriticalimportance.41Forexample,mostdrugs

andinterventionsproducedbyT1researchonlymarginallyimprovetreatment

efficacy.Furthermore,patientsmaybenefitmore(andmorepatientsmaybenefit)if

thehealthcaresystemperformedbetterindeliveringexistingtreatmentsthanin

producingnewones.Inaddition,hepointsoutthatadequateinvestmentinT2isvital

tofullysalvageinvestmentsinT1research.42

Ofnote,T2translation–whichalignscloselywithevidence‐basedmedicine–

includesbothtranslationofknowledgeintopatientcare(e.g.,creatingpatient‐specific

evidenceofclinicaleffectiveness,comparativeeffectivenessofdifferenttreatments,

andthedevelopmentofpracticeguidelines),aswellasstrategiestoaddressmore

distalquestions(e.g.,howtoreliablydeliverevidence‐basedcaretoallpatientsin

diversehealth‐caresettings,inordertoimprovethehealthofbothindividualsand

populations).Particularlyintheareaofobesityanddiabetesprevention,thedistalend

oftranslationhasincreasinglyfocusedonimprovingthehealthofthepopulation,

ratherthanspecificallyaddressingindividuals(patients)incontactwiththehealth‐

caresystem.43

Whilemany"benchtop‐to‐bedside"researchpathwayshavebeendevelopedin

T1translationalmedicinedesignedto,forexample,bringdrugstomarketfollowing

advancesinbasicscience,vehiclestofacilitateT2translationthatconvertscientific

dataintoclinicalandcommunityinterventionsdesignedtoimprovethehealthof

41S.H.Woolf,"TheMeaningofTranslationalResearchandWhyitMatters,"Journalofthe

AmericanMedicalAssociation,299(2008):211‐213.42Woolf,"MeaningofTranslationalResearch."43D.G.Marrero,"TranslatingtheDiabetesPreventionProgram,"inFromClinicalTrialsto

Community:TheScienceofTranslatingDiabetesandObesityResearch(Bethesda,MD:NationalInstitutesofHealthandCentersforDiseaseControlandPrevention,2004),49‐52.

16

humanpopulationshavereceivedlesattention.44Astheseformsoftranslational

medicineimplicatesocial,political,economicandculturalfactors,theyrequire

"integrative"researchstrategiesthatusecross‐disciplinarycommunicationtoblend

insightsfrommultiplefieldsofstudy.45

Inthisareaofresearch,thecentrifugalforcesofprofessionalspecializationand

horizontalknowledgediffusionscatterthepooluponwhichscholarsandpractitioners

drawdata.Simultaneously,centripetalforcesobligethesesamescholarsand

practitionerstosynthesizevastsumsofdiverseinformationandrendercoherent

argumentsoncomplexandmultifacetedissues.Thetaskisdifferentinkindfromsheer

informationprocessing;itdemandsformsofcommunicativedexteritythatenable

translationofideasacrossdifferencesandfacilitateco‐operativeworkbyinterlocutors

fromheterogeneousbackgrounds.Punctuatingthispoint,“[FormerNIHDirectorElias

Zerhouni]acknowledgesthatthereisno'right'modelfortranslationalresearch,buthe

isconfidentthattheNIHwilllearnaboutthebestonesbygivingtheCTSCs[Clinical

andTranslationalScienceCenters]thefreedomtoexploreadiversityofapproaches.”46

Thecommunicationchallengesinplayheremayhelpaccountforthefactthatscholars

advocatingforatranslationalresearchagendainsistthat"communicationtheory"

informeffortstoimplementtheagenda.47

Thechallengeofusingcommunicationtodealwithtensionsbornefromthe

pushandpullofcountervailingcentrifugalandcentripetalepistemologieshasancient

roots.AsJohnPoulakospointsout,"older"SophistssuchasProtagorastaughtGreek

studentsthevalueofdissoilogoi,orpullingapartcomplexquestionsbydebatingtwo

sidesofanissue.48ThefewsurvivingfragmentsofProtagoras'worksuggestthathis

44A.M.Feldman,"DoesAcademicCultureSupportTranslationalResearch?,"Clinicaland

TranslationalScience,1(2008):87‐88.45S.Mallonee,C.Fowler,&G.R.Istre,"BridgingtheGapbetweenResearchandPractice:A

ContinuingChallenge,"InjuryPrevention,12(2006):357‐359.46DeclanButler,"TranslationalResearch:CrossingtheValleyofDeath,"Nature,453(2008):

840‐2.47Woolf,"MeaningofTranslationalResearch,"211‐213.48RosamondKent,Sprague,ed.,TheOlderSophists,2ded.(Indianapolis:Hackett,2001);John

Poulakos,"RhetoricandCivicEducation:FromtheSophiststoIsocrates,"inIsocratesandCivicEducation,ed.TakisPoulakosandDavidJ.Depew(Austin:UniversityofTexasPress,2004),81‐82.

17

notionofdissoilogoistoodfortheprinciplethat"twoaccounts[logoi]arepresent

aboutevery'thing,'opposedtoeachother,"49andfurther,thathumanscould

"measure"50therelativesoundnessofknowledgeclaimsbyengagingingive‐and‐take

wherepartieswouldmakethe"weakerargumentstronger"toactivatethegenerative

aspectofrhetoricalpractice,akeyelementofthesophisticaltradition.51Oneimportant

wrinkleinthiscomparison,however,isthefactthatwhileProtagoras'dissoilogoiwas

dyadicinnature(twoargumentsopposingeachother),manifoldT2translation

projectstendtofeaturemany‐sidedarguments—henceouradaptedneologismpolloi

logoi.52

Inthefollowinggeneration,IsocrateswouldcomplementProtagoras'

centrifugalpushwiththepullofsynérchesthé,acentripetalexerciseof"coming

togetherdeliberatively"tolisten,respond,andformcommonsocialbonds.53Fourth‐

centuryB.C.Athenswasasocietyintumultuoustransition.Earlyinthecentury,

democraticreformsandwidespreadcitizentraininginpublicspeakinginfusedthe

politicalrealmwithnewactors,openingupchannelsofparticipationandtransforming

governmentalinstitutions.Butasthecenturyworeon,thiscentrifugalwaveof

populism,swellingamiddeterioratingeconomicconditions,threatenedtooverwhelm

theAthenianpolity.ItwasagainstthisculturalbackdropthatIsocratesopenedthe

west'sfirstprofessionalschool.Theschool'scurriculumreflectedthestronginfluence

ofProtagoreandissoilogoi,butIsocratesembeddedargumentationwithin

synérchesthé("comingtogetherdeliberately"),abroaderconceptthatheusedflexibly

toexpressinterlockingsensesof1)inquiry,asingroupsconveningtosearchfor

answerstocommonquestionsthroughdiscussion;542)deliberation,withinterlocutors

49EdwardSchiappa,ProtagorasanLogos:AStudyinGreekPhilosophyandRhetoric(Columbia,

SC:UniversityofSouthCarolinaPress,1991),100.50Schiappa,ProtagorasandLogos,117‐133.51Schiappa,ProtagorasandLogos,103‐116.52WeareindebtedtoJohnPoulakosforthisformulation.53EkaterinaHaskins,LogosandPowerinIsocratesandAristotle(Columbia,SC:Universityof

SouthCarolinaPress,1997),88.54Isocrates,Panathenaicus,trans.GeorgeNorlin,vol.2,LoebClassicalLibrary(London:William

Heinemann,1929),14,76.

18

gatheringinapoliticalsettingtodeliberateaboutproposedcoursesofaction;55and3)

allianceformation,aformofcollectiveactiontypicalatfestivals,56orintheexchangeof

pledgesthatdeepensocialties.57Isocratescontrastedhispaideiawiththeapproachof

earlierSophists,whotaughteloquenceasaneutralskilltobeusedforwhateverends

studentssawfit.Instead,Isocrateshighlightedthecentripetalqualitiesofsynérchesthé

asaneducationalantidotetotheincreasinglyselfishandfractiousnatureofAthenian

politics.58Hisaimwastoproducecitizensandleaderswithbroad‐basedknowledgeof

humanaffairs,alongwiththepoliticalvisionandcommunicativeabilitytoexpressthat

knowledgeforthegreatergoodofthepolis.Inshort,Isocratestaughtandpracticedthe

artofusingdeliberationasakindoftranslationmedium,capableofengendering

mutualunderstandingbybringingpeopleandideastogetherthroughcooperative

argument.

WhiletheCanadianschoolofargumentationstudieshasaphilosophicallineage,

theolderAmericantraditioninargumentationdrawsnourishmentfromthetaprootof

forensics,specificallytheappliedactivityofintercollegiatedebating.59Inthisrespect,

itisnotsurprisingtoseesophisticprinciplessuchasdissoilogoiandsynérchesthé

manifestprominentlyintheworkofcontemporaryAmericanargumentationtheorists

likeDavidZarefskyandCharlesWillard.Consider,forexample,Zarefsky'snotionof

argumentationas"hypothesistesting,"aviewthatseesargumentationasa

"communicationprocessinwhichpeoplemake,attack,anddefendclaimsinorderto

55Isocrates,Nicocles,19,OnthePeace,trans.GeorgeNorlin,LoebClassicalLibrary,vol.2

(London:WilliamHeinemann,1929),2,9.56Isocrates,Panathenaicus,146,Panegyricus,trans.GeorgeNorlin,vol.1,LoebClassicalLibrary

(London:WilliamHeinemann,1928),81.57Isocrates,Panegyricus,43,Helen,trans.LarueVanHook,vol.3,LoebClassicalLibrary

(London:WilliamHeinemann,1945),40,AgainstCallimachus,trans.LarueVanHook,vol.3,LoebClassicalLibrary(London:WilliamHeinemann,1945),45;seealsoTakisPoulakos,SpeakingforthePolis:Isocrates'RhetoricalEducation(Columbia,SC:UniversityofSouthCarolinaPress,1997),19;andHaskins,LogosandPower,8.

58Isocrates,Antidosis,trans.GeorgeNorlin,LoebClassicalLibrary,vol.2(London:WilliamHeinemann,1929).

59FransH.vanEemeren,RobGrootendorst,andFranciscaSnoekHenkemans,etal.,FundamentalsofArgumentationTheory:AHandbookofHistoricalBackgroundsandContemporaryDevelopments(Mahwah,NJ:LawrenceErlbaumAssociates,2006),193‐196.

19

gaintheassentofothersortojustifytheirownbeliefsandacts."60Duringthe1970s

and1980s,theheydayofintercollegiatedebate’s"paradigmwars,”hypothesistesting

haditsshareofadherents,someinthejudgingrankswhoappliedtheparadigmasa

toolforadjudicationofindividualcontestrounds,andothersinthedebatingranks,

whousedtheparadigmtojustifycertainargumentativestrategies(e.g.multiple,

conditionalandcontradictorynegativecounterplans).

LostinthisprocessofreductionwasZarefsky’svisionofacademicdebateasa

vehicletotransportthetheoryandpracticeofargumentationtowidersociety.61

Hypothesistesting,inthiswiderframe,wasaconstructforestablishingthegravitas

andauthorityofforensicsspecialistsinconversationsaboutthenatureof

argumentationbeyondthecontestroundsetting.Here,Zarefsky'sanalogylinking

debatetoscientifichypothesistestingwasnotdesignedtoshowhowdebateitselfwas

ascientificprocess,butrathertoalertexternalaudiencestothefactthatacademic

debate,whiledeviatingsignificantlyfromestablishedpatternsofscientificinquiry,

featuresitsownsetofrigorousproceduresforthetestingofargumentative

hypothesis.Inpublishedscholarshipandinadministrativeleadershiproles,Zarefsky

continuestourgeforensicsspecialiststocontributetheirwealthofexperiencein

designing,executing,andstudyingdebatestoprojectsbeyondthecompetitive

tournamentgridthatrequireexpertiseintheartofdeliberativedesign.T2

translationalmedicinerepresentspreciselysuchanendeavor,askeyleadersinthe

fieldhavecalledformobilizationofmulti‐disciplinaryresearchteamstosurmountthe

60DavidZarefsky,"ArgumentasHypothesis‐testing,"paperpresentedattheSpeech

CommunicationAssociationConvention,December28,1976,SanFrancisco,California.ThekernelofZarefsky'stheoryofhypothesistestingwasoutlinedinanearlierpaper,"AReformulationoftheConceptofPresumption,"presentedattheCentralStatesSpeechAssociationConvention,April7,1972,Chicago,Illinois;seealsoDavidZarefsky,"ArgumentasHypothesis‐testing,"inAdvancedDebate:ReadingsinTheory,PracticeandTeaching,ed.DavidA.Thomas(Skokie,Illinois:NationalTextbookCompany,1979),427‐437.

61DavidZarefsky,"ArgumentationandForensics,"inProceedingsoftheSummerConferenceonArgumentation,ed.J.Rhodes&S.Newell(Annandale,Virginia:SpeechCommunicationAssociation,1980),20‐25;MalcolmO.Sillars&DavidZarefsky,"FutureGoalsandRolesofForensics,"inForensicsasCommunication:TheArgumentativePerspective,ed.J.H.McBath(Skokie,Illinois:NationalTextbookCompany,1975),83‐93;seealsoG.ThomasGoodnight,"TheRe‐unionofArgumentationandDebateTheory,"inDimensionsofArgument:ProceedingsoftheSecondSummerConferenceonArgumentation,ed.GeorgeZiegelmueller(Annandale,Virginia:SpeechCommunicationAssociation),415‐432.

20

scientific,political,andcommunicativechallengesinvolvedintranslatingthefindings

ofbasicscienceintoimprovedcommunityhealthoutcomes.Zarefsky'sinsightthatthe

American,practice‐orientedtraditionofforensicsconstitutesarichstorehouseof

practicalknowledgeregardinginteractionofargument"fields"carriesparticular

relevancehere,sinceakeyaspectoftheT2translationprojectentailsfacilitating

communicationandunderstandingacrossdisparatefieldsofstudy,aswellasbetween

expertandlaycommunities.

TranslationalDeliberation

Itmaybeastretchforthosejadedbydecadesofverbalpyrotechnicscommonly

foundinCrossfire‐stylepoliticaltheatertograspthenotionthatmulti‐sidedargument

canfacilitatemutuallearningacrossepistemologicalchasms.Sincethisistheload‐

bearingpremisesupportingCharlesWillard'snotionof"epistemics,"atthispointit

maybeusefultorevisithisrationaleforconstructiveargumentasabridgingexercise.

Here,itisimportanttostipulatethatWillard'ssenseofargumentstandsincontrastto

thevernacularnotionofargumentasmerequarrelingorverbaljousting(what

Isocratescalled"wordywrangling"andJenicekterms"pimping").62Rather,Willard

viewsargumentationasa"uniquediscourseevent"thatunfoldsinthecontextofa

"socialrelationship"betweentwoormorepeople"sortingoutwhattheyconstrueto

beincompatiblepositions."63Asargumentsdevelop,"theydisplayepistemicstructure

morevividlythannormaldiscourse,fortheybringtothesurfaceassumptionsthat

wouldordinarilyremainsubmerged."Thisisbecause"argumentetiquettepermits

challengesanddemandsforclarificationandsupport,andtheseinturnyieldmore

explicitness."64

62Isocrates,Helen,trans.LarueVanHook,vol.3,LoebClassicalLibrary(London:William

Heinemann,1945),6;Jenicek,Fallacy‐FreeReasoninginMedicine,76‐77.63CharlesArthurWillard,ArgumentationandtheSocialGroundsofKnowledge(Tuscaloosa:

UniversityofAlabamaPress,1983),20‐21.64CharlesArthurWillard,LiberalismandtheProblemofKnowledge:ANewRhetoricfor

ModernDemocracy(Chicago:UniversityofChicagoPress,1996),218.

21

Asastructured"method"65ofinquiry,argumentdrivesconstructive

interchangethroughamechanismthatProtagorasidentifiedascrucialtodissoi

logoi—thatbothsidesofanargumentbetakenintoaccount.Thiselementcontainsa

calltolisten,tostepoutsideone'ssettledperspectiveinanattempttoapprehend

unfamiliarpointsofview.Argumentgenerates"practiceinmakingreflective

judgments"whileit"developsanddisciplinesthecriticalfaculties,"therebydeveloping

agencyinrespecttomakingbetterdecisionsandcommunication"choicesinthe

future."66Onesignificantoutcomeofthisrecursiveprocessisthatthecyclingaspectof

argumentstimulatesinterlocutorstoreflectupon,andinnovateintheirlanguage

usage,"byvirtueoftheirclaimsbeingarticulatedoutsidetheconfinesoftheiroriginal

disciplinarydiscourses."BuildingonWillard'stheory,SteveFullersuggeststhatjoint

enactmentofthisprocessorientsacademicscholarstothechallengeof

interdisciplinarytranslationby"spawning"so‐calledpidginlanguages,"which

reinforcedandextendedovertimecoulddevelopintoaninterdisciplinarylingua

franca."67

Certainly,thistypeofintegrativescientificresearchhasimpressivehistorical

precedents.Forinstance,physicistErwinSchrödingerandbiologistTheodosius

Dobzhanskydeployedinventiverhetoricaldevicesandstrategiestoforgeconceptual

bridgesconnectingmultiplescholarlyaudiences.Dobzhansky'scleveruseof

topographicalmapstovisuallydepictmathematicalpopulationgeneticshelped

biologistsandgeneticistsreachcommonunderstandingsthateventuallyyieldedthe

"modernsynthesis"ofevolutionarybiology.Inasimilarfashion,Schrödingerdeployed

"polysemy,"arhetoricalstrategyofdesigningtextstobereadinmultiplewaysby

65DouglasEhninger,"ArgumentasMethod:ItsNature,itsLimitationsanditsUses,"Speech

Monographs,37(1970):101‐110;seealsoDouglasEhninger&WayneBrockriede,DecisionbyDebate(NewYork:Dodd,Mead&Company,1972);MauriceNatanson,"TheClaimsofImmediacy,"inPhilosophy,RhetoricandArgumenation,ed.MauriceNatansonandHenryW.Johnstone,Jr.(UniversityPark,PA:PennStateUniversityPress,1965),10‐19;andJackW.Meiland,"ArgumentasInquiryandArgumentasPersuasion,"Argumentation,3(1989):185‐196.

66Ehninger,"ArgumentasMethod,"102;seealsoHenryW.Johnstone,Jr.,"SomeReflectionsonArgumentation,"inPhilosophy,RhetoricandArgumenation,1‐9.

67SteveFuller,TheGovernanceofScience(Buckingham:OpenUniversityPress,2000),142;seealsoFuller'sPhilosophy,Rhetoric&theEndofKnowledge:TheComingofScienceandTechnologyStudies(Madison:UniversityofWisconsinPress,1993),44‐48.

22

differentaudiences,toinspirecreativeconversationsbetweenphysicistsand

biologiststhatultimatelygaverisetothehybridfieldofmolecularbiology.68

YetwhererhetoricalcriticLeahCeccarellifindsinthisgenreof"inspirational

interdisciplinarity"arecurrentfeaturethatsuchproseisissuedbyscholarlygiants

withtranscendentpersonas,today'stranslationalmedicinemovementcallsfor

institutionalizationoftranslationalresearchasaroutineformofprofessionalactivity.

Willard'spointthat"differencesamongindividualsanddiscoursesputapremiumon

translation"69highlightshowtheterm"translationalmedicine"herecarriesdouble

meaning.Itsmetaphoricdimensiondescribestheprocessofmovingbasicscience

downtheconveyorbelttoappliedsettings.Butsincethisprocessrequiresintegrative,

cross‐disciplinarycollaboration,theenterprisenecessarilyalsoentailstranslationin

theliteralsense,theinventionofsharedlanguagescapableofbridgingdisparate

epistemiccommunities.ThecontributionsofAmericanargumentationscholarssuchas

WillardandZarefskyindicatethatdeliberativeargumentation("synérchesthé"and

"polloilogoi"intheadaptedsophisticallexicon)haspotentialtoserveasavaluable

translationvehicleforthistask.

DeliberationandArgumentCogency

Theprevioussectionexploredhowcontemporaryformsofpolloilogoican

facilitatetranslationalcommunicationbetweendistinctfieldsofscholarlyinquiry.

Whatabouttranslationacrosstheexpert‐publicboundary?Oneimportantfinding

fromphilosopherWilliamRehg'snewbook,CogentScienceinContext,isthatthese

twotranslationchallengescanbeviewedastwosidesofthesamecoin.Rehg

elucidatesthisconnectionbyreconstructingthenotionofargument"cogency,"

especiallyasitrelatestotheevidentiarydimensionofargumentativepractice.He

beginsbynotingthatcogencyisapromising"boundaryconcept,"byvirtueofthefact

thatithasacommonlyacceptedgeneralmeaning(roughlysynonymouswiththe

68LeachCeccarelli,ShapingSciencewithRhetoric:TheCasesofDobzhansky,Schrödinger,and

Wilson(Chicago:UniversityofChicagoPress,2001).69Willard,LiberalismandtheProblemofKnowledge,309.

23

"strengthorconvincingqualityofarguments"),andalsopossesses"thebreadthand

flexibilitytocoveralargeterritoryofapproachestoargumentevaluation."70Rehgthen

proceedstodevelopatieredmodelofargumentcogencythatexplainshowscientific

argumentsexhibitmeritatthethreelevels:

•Contentmerit:Thedegreetowhichthestructureofanargument

adherestodomain‐specifictopicalandlogicalrequirements(ata

minimumhavingapremiseandaconclusion).

•Transactionalmerit:Thequalityofdialogicexchangebetweenparties

conductinganargument(especiallywhentheargumentspans

disciplinaryboundaries).

•Publicmerit:Theabilityoftheargumenttoappealtoawider

reasonablepublicthatfindsitrelevant,thought‐provoking,or

convincing.71

AppliedtoT2translationalresearch,Rehg'stheoryofcogencycallsattentionto

therelationshipsbetweenanargument'scontent,transactionalandpublicmerits.

Thesenuancesthatareespeciallywellsuitedtoaccountforakeydynamicnotedby

Fuller,thatwhenscientistsfromdifferentfieldsgainopportunitiesforconstructive

inter‐fieldargumentation,

Onceprovidedwithanincentivetointerrogateeachother'sclaims,the

scientiststhemselveswouldbeinapositiontointensifythe

investigation,strippingawaygratuitousjargon,overstatementandall‐

aroundobfuscationthatmightotherwisemystifynon‐experts.Thus,

whatoriginallyappearedtobetheincommensurableknowledge

productsoftwodisciplines—suchasthetheoreticalbenefitsofabranch

ofphysicsandthepracticalbenefitsofabranchofbiology—wouldbe

renderedcomparable...Weredisciplinarycommunitiesmadetobe

routinelyaccountabletoeachother,thenmuchoftheauraofexpertise

70WilliamRehg,CogentScienceinContext:TheScienceWars,ArgumentationTheory,and

Habermas(Cambridge,MA:MITPress,2009),7.71Rehg,CogentScienceinContext,250‐251.

24

andesotericknowledgethatcontinuestokeepthepublicatarespectful

distancefromscientistswouldberemoved.72

Rehg'stheoryofargumentcogencythusprovidesoneavenueformoving

beyondtheunidirectional,siloedmodelfortranslation,whereasingleexpertfield

reachesouttoanaudienceofcitizens/policy‐makers(seeFigure2).

[InsertFigure2abouthere]

Incontrasttothisunidirectionalmodel,theinterdisciplinarytransactionsthat

facilitatetranslationalresearchgeneratelanguagethatnotonlyenablesthesortof

integrativeresearchintheexpertrealm.Such"pidginlanguage,"thankstoits

"fungibility,"haspotentialtobridgeunderstandingbetweenexpertandlayaudiences,

aswell(seeFigure3).73

[InsertFigure3abouthere]

ThecuriouscaseofaspirinhelpsconcretizeRehg'sconceptofhowdeliberation

intranslationalresearchcanpossiblygeneratecogentargumentswithpublicmerit.

Gold‐standarddataestablishthatuseofaspirinbypatientswhohavepreviously

experiencedastrokehelpspreventrecurrentstrokes.74Yetonestudyfindsthatthis

simple,inexpensivetherapyisgivenonlyto58%ofeligiblepatients.75Thisgap

betweenevidenceandpracticereflectsthepresenceofcomplexT2translational

blocksthataccountforwhyahealthcaresystemisunabletorealizesubstantialhealth

caregainswhencompellingscienceclearlyshowsthewayforjustunder5centsa

72Fuller,GovernanceofScience,142.73ThisdynamicbringstomindIsocrates'dictum,"thesameargumentswhichweusein

persuadingotherswhenwespeakinpublic,weemployalsowhenwedeliberateinourownthoughts"(Nicocles,8).

74Aspirincanreducestrokerecurrencebyasmuchas23%:"CollaborativeMeta‐analysisofRandomisedTrialsofAntiplateletTherapyforPreventionofDeath,MyocardialInfarction,andStrokeinHighRiskPatients,"BritishMedicalJournal,324(2002):71‐86.

75E.A.McGlynn,S.M.Asch,andJ.Adams,etal.,"TheQualityofHealthCareDeliveredtoAdultsintheUnitedStates,"NewEnglandJournalofMedicine,348(2003):2635‐2645.

25

day.76AccordingtoStephenWoolfandRobertJohnson,overcomingthesebarriers

requiresmorethanjustpublicationofclinicalguidelinesrecommendingaspirin

prescriptionsforstrokepatients.Rather,WoolfandJohnsonholdthatsurmounting

suchtranslationalblockagesrequiresmacro‐levelapproachestoenhance

communicativecooperationandfacilitateinformationflowsbetweenhealthcare

professionalsandcivicpartners(parallelingthe"allianceformation"functionof

Isocraticsynérchesthé).77

WoolfandJohnson'sanalysispointstothepotentialvalueofdeliberative

argumentasatooltofacilitatetranslationalstrategies.Intheaspirincase,onemight

imagineaninterdisciplinaryresearchteamengaginginstructureddebateoverthe

relativemeritsofcompetingapproachestoovercomeT2translationblocks.Tothe

extentthattheteam'spolloilogoiwouldexhibitwhatRehgcallsstrong"transactional

merit"(interlocutorsarguecooperatively,takerisks,andairsuppressedpremises),the

exercisewouldbeprimedtopercolatecogentargumentswithpublicmerit.According

toRehg'stheory,thesecogentargumentswouldhavepotentialtopersuasivelyframe

strokepreventionthroughaspirintreatmentasapressingandrealisticallyachievable

objectiveforwideaudiences.AsWillardputsit,"eachstageoftranslationfrom

esoterictoexotericrequiresnewsimplificationsandmetaphors."78Notably,this

inventionalchallengediffersinemphasisfromthe"fallacy‐free"programofargument‐

basedmedicineoutlinedbyJenicek,wherethefocusliesonavoidingerrorsin

reasoning,ratherthanproductionofcogentargumentstofacilitateT2translation.79

76TheBritishMedicalJournal's"CollaborativeMeta‐analysis"concludesthatlowdoseaspirin

(75‐150mgdaily)isaneffectiveantiplateletregimenforlong‐termuseinstrokeprevention.InMay2009,Walgreens'websiteadvertisedabottleof125tabletsofregular(325mg)genericbrandaspirintabletsfor$5.99(eachtabletcostingapproximately4.8cents).

77StevenH.WoolfandRobertE.Johnson,"TheBreak‐EvenPoint:WhenMedicalAdvancesareLessImportantthanImprovingtheFidelitywithwhichtheyareDelivered,"AnnalsofFamilyMedicine,3(2005):545‐552.

78Willard,LiberalismandtheProblemofKnowledge,107.79Nevertheless,thisdistinctionshouldnotbeoverdrawn,asitiseasilypossibletoimaginethe

twoapproachesworkinginconcert,justasCanadianandAmericanargumentationscholarscooperatetoelucidatemultipleanglesofargumentativephenomenaatinternationalconferencessuchastheonehostedseriallybytheUniversityofAmsterdam'sInternationalSocietyfortheStudyofArgumentation.

26

DeliberationandPhysician‐Citizenship

WoolfandJohnson'sblueprintforovercomingT2translationblocksasks

physicianstoengageinmodesofpublicadvocacythatdriftquitefarfromthe

traditionalclinicalsetting.Theirlistofpossiblephysician‐drivenpublicargument

campaigns(e.g.pressingforuniversalhealthinsurance,restructureddeliveryand

reimbursementsystems)80mayseemoutofplacetopractitionerstrainedinafield

wherepublicadvocacyskillsreceivelittleornocurricularcoverage.Yetthiscallfor

physician‐drivenpublicadvocacyisechoedbytopleadersinthefield.

TimothyGardner,presidentoftheAmericanHeartAssociation(AHA),recently

gaveamajoraddresstofellowphysicians,healthcareprovidersandcardiovascular

researchers,saying:"Iwantustoacknowledgeoursharedmissionascitizenleaders

andchallengeourselvestoconsidertheimplicationsofthisrallyingcry."81Pushinghis

expertconstituentstobroadentheirprofessionalidentitiestoincludeapolitical

component,Gardnersuggested,"Ascitizenleaders,wemustalsotakeaprominent

publicstanceinsupportofpoliciesthatpromotehealthinourcommunities."82

Gardner'scallforhealthcareprofessionalstoembraceadvocacyrolesas

"citizenleaders"harmonizeswithanearlierstatementbyRussellGruen,Steven

PearsonandTroyenBrennan,whourgedtheirpeersinthemedicalprofessionstoact

ontheirabilitytobe"publicwitnesses"tosocioeconomicdeterminantsofpatients'

healthand"providethesortofinformationandprofessionalauthoritythatbrings

veracityandlegitimacytotheseconcernsinpublicdebate."83Toillustratemodesof

80WoolfandJohnson,"BreakEvenPoint,"550.81TimothyJ.Gardner,"BuildingaHealthierWorld,FreeofCardiovascularDiseasesandStroke:

PresidentialAddressattheAmericanHeartAssociation2008ScientificSessions,"Circulation,119(April7,2009):1838.

82Gardner,"BuildingaHealthierWorld,"1840.AsGardnerexplainsfurther,"Eachofushasourownuniqueandveryimportantroletoplayintheworkofbuildingahealthierworld,bethatasanurse,aresearcher,aclinician,analliedhealthworker,ahealthsystemadministrator,oranadvocateagainstcardiovasculardiseaseandstroke.Butinadditiontoourspecificrole,eachofusisacitizeninourcommunityandsociety.Lettheaccomplishmentstodateoftheantismokingmovementinspireustodomoretoensurethatriskfactorreductionandthepromotionofhealthfulnessareembeddedinourcultureandinourpublicpolicy"("BuildingaHealthierWorld,"1841).

83RussellL.Gruen,StevenD.PearsonandTroyenA.Brennan,“Physician‐Citizens–PublicRolesandProfessionalObligations,”JournaloftheAmericanMedicalAssociation,291(2004):95.

27

politicalengagementopento"physician‐citizens,"Gruen,PearsonandBrennancited

examplessuchas:

•Raisingpublicawarenessaboutahealthorsocialissuebydiscussingit

withfamilyandfriendsorparticipatinginapublicforum.

•Writingaletter,signingapetition,orparticipatinginanotherformof

publicadvocacyandlobbying.

•Encouragingamedicalsocietytoactonanissuethatconcernsthe

public’shealth.

•Organizingandformingagroupforpoliticaladvocacy.84

ItisnotablehowthesesuggestionsreflecttheIsocraticthemeofcollective

actionthroughsynérchesthé.Gruen,PearsonandBrennanemphasizehowtheircall

forpoliticalengagementbyhealthcareprofessionalsisdesignedtotranscend

particularpoliticalideologiesandpromotethecommongoodthroughpublic

deliberation:"Wehaveframedpublicrolesasissuesofevidenceandprofessionalism,

notasmattersofindividualpoliticalpersuasion."85Thisthemeofevidence‐based

politicaladvocacyundertakenbyhealthcareprofessionalsasanexpressionof

citizenshipcanbeseenasanoutgrowthoftheEBMmovementstartedintheearly

1990s.ButwhereasEBMwasdevelopedasanapproachtosharpenphysicians'clinical

decision‐making,thecallsforphysiciancitizenshipandT2translationalresearchdiffer

inkeyrespects.First,thelatterformsofprofessionalactivitynecessarilydemanda

uniquelevelofintegrative,interdisciplinaryexchange(evenmoresothanclinical

practice).Second,sincephysiciancitizenshipandT2translationalresearchentail

84Gruen,PearsonandBrennan,“Physician‐Citizens,"97.85Gruen,PearsonandBrennan,“Physician‐Citizens,"98."Physiciansmustrealizethattheyalso

sharegoalsincommonwithothermembersoftheprofessionandthat,althoughindividualactionislaudable,collectiveactionisahallmarkofprofessionalism.Physiciangroupshavebeenparticularlyeffectiveagentsofchangeininstitutionalissues,localcommunitymatters,legislativeaction,andmuchbroaderissues,suchascivilandhumanrights,preventionofnuclearwar,andthebanningoflandmines.Theselargermovementshaveshownphysicianadvocacytobemosteffectivewhenithasaspecificgoal,aclearmessage,goodsupportingevidence,collectiveaction,andparticipationinthepoliticalprocess"(Gruen,PearsonandBrennan,97)."Physiciansshouldbereassuredthatevensmallactionscanbeinfluential,thatpoliticalinvolvementismorethanjustvotinginelections,andthattheseactivitiesareimportantandadmirableaspectsofcitizenship"(97).

28

publicengagement,theyrequiretranslationnotonlyacrossdisciplinaryboundaries,

butalsoacrossbarriersthatdivideexpertandpubliccommunities.

Conclusion

DilipGaonkar'ssharpattackontherhetoricofscienceresearchprogram

chargesthatscholarssuchasJohnCampbell,LawrencePrelli,andAlanGrosscommita

translationerrorbyutilizingconceptsfromclassicalGreekrhetoricasahermeneutic

metadiscourseforinterpretingscientifictexts.86InGaonkar'stelling,the"hegemonic"

projectto"globalize"rhetoricbybringingalltextualartifacts(evenhardscience)

underitsscopeisanill‐fatedexerciseinsupply‐sideepistemology.Thestakesarehigh,

sinceasGaonkarwarnsnearthecloseofhislandmarkessay,"globalizationseverely

underminesrhetoric'sself‐representationasasituatedpracticalart."87

Gaonkar'sbroadsidehitsclosetohome,asthistooisarhetoricofscienceessay,

onethatleansheavilyontheconceptoftranslation.Yetelementsoftheforegoing

analysisreversethethrustofGaonkar'scritique.Leadingmedicalscholarsshapethe

agendaoftranslationalresearchbyopenlyforegroundingthecommunication

challengesinherentinthekindofintegrative,trans‐disciplinaryresearchnecessaryto

overcomeT2translationalblocks.Theyalsocallforscholarlycontributionsfromthe

fieldofcommunication,notforhelpwiththeinterpretivetaskofcriticizingscientific

texts,butratherforsupportinsynérchesthé,theperformativetaskofcomingtogether

deliberatelyforthepurposeofjointinquiry,collectivechoice‐making,andrenewalof

communicativebonds.

Hereisdemand‐siderhetoricofscience,wherescientificactorsseekenlistment

ofrhetoric'sexpertise.Ratherthanrhetoricpushingitsepistemologyonscience,we

havesciencepullingrhetoricintoitsinterdisciplinaryorbit.The"thinness"ofthe

productivistclassicalGreeklexicon,supposedlyaliabilityinrhetoricalcriticism,here

86DilipParameshwarGaonkar,"TheIdeaofRhetoricintheRhetoricofScience,"inRhetorical

Hermeneutics,ed.AlanG.GrossandWilliamM.Keith(Albany,NY:StateUniversityofNewYorkPress,1997),25‐85.

87Gaonkar,"IdeaofRhetoric,"76.

29

becomesastrengthsupportingthetypeofpractice‐orientedscholarshipthatZarefsky

envisionedgrowingoutofhistheoryofargumentationas"hypothesistesting."

InfairnesstoGaonkar,itshouldbestipulatedthathis1993critiquechallenged

thewayrhetoricofsciencehadbeendonetodate,nottheuniverseofwaysrhetoricof

sciencemightbedoneinthefuture.Andtohispartialcredit(hedidthisinafootnote),

Gaonkardidacknowledgethepromiseofaperformance‐orientedrhetoricofscience,

especiallyoneinformedbyclassicalthinkersotherthanAristotle.88Infact,onewould

expectGaonkartoholdsuchanuancedposition,givenhisintellectualbackground.

MentoredattheUniversityofPittsburghbyfoundingrhetoricianofscienceTrevor

Melia,aswellaslegendaryforensicsdirectorRobertNewman,GaonkarwrotehisPh.D.

dissertationon"AspectsofSophisticPedagogy."89Inthatdot‐matrixtome,Gaonkar

documentshowtheancientsophistswere"thegreatestchampions"of"socially

useful"science,90andalsohowthesophistsessentiallypracticedtheartofrhetoricina

translationalregister:

Thesophistscouldnotblithelygoabouttheirbusinessofmakingscience

useful,whilescienceitselfstoodstillduetolackofcommunalsupport

andrecognition.Besides,sophisticpedagogywasbecomingincreasingly

dependentonthefindingsofcontemporaryspeculationinphilosophy

andscience.Takeforinstance,theeminentlypracticalartofrhetoric.As

taughtbythebestofthesophists,itwasnotsimplyahandbookof

recipeswhichanyonecouldmechanicallyemploytohisadvantage.On

thecontrary,thestrengthandvitalityofsophisticrhetoriccamefrom

theirabilitytoincorporatetherelevantinformationobtainedfromthe

on‐goingresearchinotherfields.91

Ofcoursedeeptrans‐historicaldifferencesmakeuncriticalappropriationof

classicalGreekrhetoricforcontemporaryuseafool'serrand.ButtogaugefromRobert

88Gaonkar,"TheIdeaofRhetoric,"note3,78.89DilipParameshwarGaonkar,"AspectsofSophisticPedagogy,"unpublishedPh.D.diss.,

UniversityofPittsburgh,Pittsburgh,Pennsylvania,1984.90Gaonkar,"AspectsofSophisticPedagogy,"121.91Gaonkar,"AspectsofSophisticPedagogy,"248,emphasisadded.

30

Hariman'srecentreflectionsontheenduringsalienceofIsocrates,"timely,suitable,

andelegantappropriations"canhelpuspost‐moderns"forgeanewpoliticallanguage"

suitableforaddressingthecomplexraftofintertwinedproblemsfacingglobal

society.92Suchretrospectionislongoverdue,saysHariman,as"thehistory,literature,

philosophy,oratory,art,andpoliticalthoughtofGreeceandRomehaveneverbeen

moreaccessibleorlessappreciated."93

Fortunatelytheprojectofre‐connectingwithourfield'ssophisticrootsis

leveragedimmeasurablybythepresenceofafewsophosinourmidstwhose

intellectuallineagecanbetraced,albeitcircuitously,totheoriginalsophists—

ProtagorasandIsocrates.Theinter‐generationalconnector,inthiscase,isforensics—

thepracticalenterpriseofcooperativelycompetitivespeech‐making.Onefindsearly

instantiationsofforensicsinProtagoras'pedagogicalmethodofdissoilogoi,aswellas

precursorstowhatwenowthinkofaspublicdebateinIsocraticlogospolitikos.Inthe

early20thcentury,luminariessuchasWaylandMaxfieldParrish,FrankHardyLane,

andevenHerbertWichelns(himselfadebatecoachattheUniversityofPittsburgh),re‐

animatedthesophistictraditionbydevelopingnewformsofpublicdebateandpublic

speaking,activitiesthatservedasafulcrumthatthenascentfieldofcommunication

wouldusetosplitofffromEnglish.DavidZarefskydescendsfromthatsamelineof

intellectualforebears.Thebestofthesophisticaltraditionisevidentinhis

performancesasachampiondebaterandcoach,hisprofessionalleadershipofan

academicfield,andhisscholarlywritingsonargumentationtheoryandpractice.

92RobertHariman,"CivicEducation,ClassicalImitation,andDemocraticPolity,"inIsocrates

andCivicEducation,228.93Hariman,"CivicEducation,"217.

31

Appendix:TablesandFigures

Table1.ResultsofaNLMsearchforarticlesfocusingonEvidence‐BasedMedicineinselectedyearsbetween1990and2008*

Year of Publication

Number of Articles

1990 0 1992 2 1994 12 1996 245 1998 1095 2000 1957 2002 2809 2004 3383 2006 4177 2008 4744

* search performed 5/24/2009

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Figure1.Evidence‐BasedMedicineHierarchyofEvidenceTypes.Permissionpending.

33

Figure2.Unidirectionalmodelfortranslationofevidencefromsiloedexpertfieldstowiderpublicsandpolicymakers.

34

Figure3.Translationthroughpolloilogoi.Argumentationbetweenexpertscholarlyfieldsgeneratesbridginglanguagethatsupportscogentevidence.Thisfacilitatesintegrativeresearchandsupportstranslationeffortsdesignedtocommunicatefindingstowiderpublicsandpolicy‐makers(adaptedfromRehg,CogentScienceinContext).