From Knowledge to Practice: Why Frameworks Alone Aren’t Enough

I have spent a lot of my career working with frameworks, toolkits, models of practice, and educational resources. I believe in them. I create them. I use them. I teach from them.

I have also become increasingly cautious about what we expect them to do.

A good framework can give us language for something we have struggled to name. It can bring research, lived experience, and practice knowledge together. It can establish shared commitments and help us notice things our systems and sometimes we ourselves have overlooked.

But a framework cannot make us relational. It cannot make us curious. It cannot make us listen. And it certainly cannot tell us exactly what the person sitting across from us needs.

That part happens in practice.

And practice is much messier.

There is a phrase we use all the time in healthcare: “We need to meet patients where they are at.”

I have used it myself. But the more I think about it, the less comfortable I am with it.  Can we really meet someone where they are?

I don’t think we can.

I can sit beside someone. I can listen. I can believe what they tell me. I can become curious about their experience. I can acknowledge what I don’t understand and resist filling those gaps with my own assumptions.

But I cannot arrive at exactly the same place they are standing because I didn’t travel the road that brought them there.

Their history is not mine. Their body is not mine. Their experiences of illness, disability, healthcare, discrimination, family, loss, safety, and trust are not mine. Even when parts of our experiences appear similar, the paths that brought us there are different.

Perhaps our responsibility as healthcare professionals isn’t to meet patients where they are at.  Perhaps it is to recognize that they are somewhere we have not been and become curious about what it took to get there.

That distinction matters. It shifts us from assuming we understand to asking what we don’t yet know.

I learned this before I had language for it

Long before I was developing frameworks or thinking deeply about relational practice, I experienced this from the other side of healthcare as Sophia’s caregiver.

Sophia lived with a rare and complex disease. Not everything she experienced had an obvious clinical explanation. Pain was one of those things.  There were times when she was clearly in significant pain, but no one could easily explain why. Was it physical? Emotional? Psychological? Related to her disease?

Those were legitimate clinical questions.  But I also knew something:

My daughter was in pain.

I knew what Sophia looked like when she was hurting. I knew the subtle changes in her face and behaviour. I knew her patterns. That knowledge wasn’t written in her chart or produced through a clinical assessment. It came from years of loving her, caring for her, watching her, and learning her.

Sometimes we had to fight very hard for that knowledge to count.  What we needed wasn’t for someone to “meet us where we were at.”   We needed people willing to come toward us with curiosity:

• Tell me what you’re seeing.
• What is different today?
• What have you learned about her pain?
• What do you think we might be missing?

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Those questions don’t diminish clinical expertise.  They expand it.

What a missed appointment doesn’t tell you

There is another experience with Sophia that I think about often, particularly when I hear healthcare professionals talk about engagement, adherence, or missed appointments.  There was one specialty clinic where I rarely managed to get Sophia to her appointments or sometimes, we arrived but couldn’t stay for the entire visit.  It wasn’t because that part of her condition wasn’t important. It wasn’t because I didn’t value the specialist. And it certainly wasn’t because I wasn’t engaged in her care.

The reasons were far more complicated.

The clinic was in an older part of the hospital that was awkward to access from the underground covered parking we relied on. That might sound insignificant until you imagine navigating a hospital with a child in a wheelchair, oxygen tanks, medications, feeding supplies, and everything else that travelled with us.

Sophia’s health was compromised. The waiting room was often packed with children coughing and sneezing. For me, sitting there meant calculating what an ordinary respiratory infection could mean for her.

There was little privacy. Intake questions could be heard by everyone around us. As a queer family, there were times when that lack of confidentiality made us particularly uncomfortable.

And then there was time.

I appreciated that we were in a teaching hospital and understood the importance of medical students and residents learning. But we were also a family trying to stack specialist appointments whenever possible not for convenience, but because managing healthcare had become a significant part of managing our lives.

Every visit involved calculations largely invisible to the people waiting for us inside the clinic:

• How much oxygen remained in Sophia’s tanks?
• When did she need medication or a feed?
• Where could I do those things safely and privately?
• Would we make the next appointment?
• How much work would I miss?
• What would travel and parking cost?
• How much energy did Sophia have left?
• How much energy did I have left?

A half-hour appointment could become three hours when multiple learners saw Sophia before the specialist.  Three hours wasn’t simply inconvenient. It affected oxygen, medications, feeds, other appointments, and Sophia’s ability to tolerate the day.

We were exhausted.  Yet I don’t remember anyone asking:
“What makes it difficult for you to get Sophia here?”

From the system’s perspective, we were a family repeatedly missing appointments.

From inside our lives, I was making a risk-benefit decision every time:
Is the value of this appointment today greater than the physical, logistical, financial, and emotional cost of getting Sophia there?

Sometimes the answer was no.  That wasn’t disengagement.  That was caregiving…
 
And then we ended up in Emergency

Eventually, Sophia ended up in Emergency in crisis. Part of what was happening intersected with the specialty whose appointments we had struggled to attend.  The specialist came to see us with a learner, and very quickly the missed appointments entered the conversation.

I don’t remember every word. I remember how it felt.  The language, tone, and energy seemed to carry the same message:

You missed these appointments. This is part of why you are here. And now this is what you must do.

We felt admonished. We felt shamed. We felt responsible.  And context was almost entirely absent.  Sophia was about six months from the end of her life. By then, our priorities had changed dramatically. We were increasingly living in what I came to think of as the breathing, bleeding, broken bones stage of her care.

• Could she breathe?
• Was she bleeding?
• Was something broken?
• Was she in pain?
• What did we need to deal with today to get her through today?

There were many important aspects of Sophia’s care. But when you are caring for a medically complex child whose health is deteriorating, everything cannot remain the highest priority at the same time.  That particular specialty simply wasn’t in our eyeline during that crisis.  That didn’t mean we didn’t care.

Other things had become more urgent.

And sitting in Emergency, while our child was in crisis, was not the time or place to account for our previous attendance. 

What I don’t remember hearing were questions like:

• What has been happening for your family?
• What matters most for Sophia right now?
• What has made accessing our clinic difficult?
• Could we provide this care differently?
• What do you need from us right now?

None of those questions would have changed the clinical concern.  But they could have completely changed the encounter.

No one asked how the clinic itself might adapt. The assumption seemed to be that we needed to do better at getting Sophia to them.  No one seemed to consider whether they could do better at getting their care to Sophia.

That difference has stayed with me.

A fact and an interpretation are not the same thing

I think about this experience when I hear words like non-compliant, disengaged, frequent no-show, or difficult to reach.
A missed appointment is a fact.

“Disengaged” is an interpretation.

And interpretations can become stories about people. They enter charts, travel between providers, and influence how the next healthcare professional enters the room.  Before long, the patient or family can become the problem rather than someone experiencing a problem with accessing our system.

The goal isn’t to replace one assumption with another. It is to remain curious long enough to find out.
Instead of asking, Why won’t this patient engage?, we might ask:

• What don’t we understand about this person’s circumstances?
• What does it take for them simply to access our care?
• What competing priorities are they managing?
• What assumptions are we making?
• What could we change?

That last question matters.

Who actually needs to move?

This is why I struggle with “meeting patients where they are at.”  The phrase subtly centres the health care professional and/or team who are positioned as the stable point, travelling toward the patient. And too often healthcare then defines where the patient is: not ready, resistant, non-compliant, not engaging.

When I think about Sophia, I find myself asking:
Who actually needed to move?

Could every appointment have needed to be in person? Could we have bypassed a crowded waiting room? Could sensitive questions have been asked privately? Could the number of learners have been negotiated? Could there have been somewhere to manage medications and tube feeds?

And as Sophia became sicker, could someone have asked:
Does what our specialty considers a priority still align with what matters most to Sophia and her family right now?
Every specialty understandably sees the importance of the area it is responsible for.  Patients and families live all of those areas at once.  Something can be clinically important and still not be the most important thing right now.  That isn’t rejecting care.  Sometimes that is what prioritizing looks like from inside a person’s life.

This is where frameworks matter

I continue to believe deeply in frameworks but perhaps differently than I once did.

A trauma-informed framework can remind us to consider safety, trust, choice, and power. A strengths-based framework can help us notice capability rather than beginning with deficits. A relational framework can remind us that what happens between people matters. An equity-oriented framework can help us ask whose knowledge is valued and who is continually being asked to adapt.

But the framework cannot tell us what those things look like for the person sitting in front of us.  The framework might tell us to improve access.

Practice asks us to understand what “access” looks like from a wheelchair, with an oxygen tank and feeding supplies, while worrying about infection and watching the clock.

The framework might tell us to centre patients and families. 

Practice requires us to believe they hold knowledge we don’t.

The framework might tell us to “meet patients where they are.”

Practice requires us to acknowledge that we may not actually understand where they are at all.
The framework isn’t the practice

Over time, I have become less interested in whether someone can recite the principles of a framework and more interested in what happens when those principles become inconvenient.

What happens when a patient says no? When a family challenges our interpretation? When lived experience conflicts with professional assumptions? When someone tells us something we designed to be accessible isn’t accessible to them?

Those are the moments when our values become visible.

Embodied practice can look surprisingly ordinary:

• Pause before interpreting someone’s behaviour.
• Ask rather than assume.
• Notice whose knowledge is missing.
• Ask, “What matters most right now?”
• Be willing to change the plan.
• Recognize when professional authority is taking up too much space.
• Repair when we get something wrong.

No toolkit can guarantee those things.  But a good framework can create the conditions for us to practice them.

Creating possibility, not prescribing practice

I think of frameworks as scaffolding.  Scaffolding gives us something to hold onto while we build. It provides structure and orientation.  But the scaffolding isn’t the building.

The framework isn’t the relationship. The toolkit isn’t the practice. And completing the training isn’t the transformation.

Eventually, the principles have to leave the page and enter the complicated, imperfect, relational world of people.
The frameworks I value most don't prescribe a single right way of being.

They create possibility.

And perhaps most importantly, they remind us that we are not experts on someone else’s journey.

I don’t think we can truly “meet patients where they are at.”  We haven’t travelled their road.  But we can move toward them.

We can listen. We can become curious about what we don’t understand. We can ask what matters most right now. We can bring our expertise without assuming it is the only expertise that matters.

And sometimes, rather than asking patients and families to move toward the system, we need to ask what the system could move, change, or let go of to make care more possible.

So rather than asking only, Are we following the framework?, I find myself asking:

• What is this framework helping me notice?
• What am I assuming?
• Whose knowledge am I privileging?
• What don’t I understand yet?
• What is being asked of this patient or family simply to access our care?
• What could we change rather than expecting them to change?
• Am I willing to let what I learn change how I practice?

Because a framework should never be the end of our thinking.

It should create possibility not prescribe a single way of being.

And perhaps the real measure of a framework isn’t whether we can demonstrate that we implemented it. 
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Perhaps it is whether, because of it, we notice differently, listen differently, relate differently, and ultimately practice differently.