EBP as a blame game

This is the second of three consecutive blog posts on the research-to-practice gap,
​and factors that are typically missed.

aka: EBP flame wars and journal articles used as weapons of mass destruction
aka: How to convince people to frolic in the field of research with you by holding a flower to their nose instead of a gun to their head
aka: All great things are built upon a foundation of solid relationships
aka: Which matters more: facts or people’s feelings? … and I’m just going to answer that question for you and say “both”

People reading this post likely fall into one of two categories: 1) You know exactly why I’m writing this, and you already have your “preach hands” up, or 2) You have no idea what I’m talking about, or why I would even open this discussion. If you fit in the latter category, I hope I can coherently explain the issue. I’ll give it a whirl...
 
Let’s start with the backstory:
​
Once upon a time, the field of speech–language pathology realized that in order to act in our clients’ best interests, we need to be using evidence-based practice (of course this has been an interdisciplinary, international thing, but for now we’ll discuss it only as it applies within our field). Traditionally, SLPs have done well with the clinical expertise and clients’ needs portions of this. They’ve done less well with taking research evidence into consideration. Why would that be? Perhaps because the research is so far away from us. It’s hard to get, it’s hard to wade through, and it’s time-consuming to interpret. Simply put, there are high (and numerous) barriers between clinicians and the evidence, with two of the big ones being access and utility. And to-date, we haven’t been all that honest with each other about those barriers. Ultimately, this lack of communication, lack of frankness, and abysmal acknowledgment of clinical reality has impeded our ability to make the “research” corner of EBP realistic and achievable.

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Along the way:

​Along the way, many people have tried to solve this research-to-practice gap. Many have done so while minimizing (or not adequately recognizing) the barriers clinicians face. So, instead, we have tried to close the research-to-practice gap in the following ways:

• By telling clinicians they need to know the evidence.
• By explaining to them that it’s unethical to not know the evidence.
• By explaining that knowing the evidence is actually in their best interest, because it makes their practice more effective, efficient.
• By explaining research articles (“Hey there, lemme science-splain you what correlation is…”), instead of focusing on research applied to practice. (As if only they could recall that graduate-level Research Methods course, everything would be better.)

All this expectation that it's clinicians' jobs to jump the research-to-practice gap. All this explaining. As though clinicians don't understand the logic behind why they should know the research. 

So, has this worked?

​I don’t know, has it? Do you feel like it has?

I’m really not the person to comment on the progress that’s been made over the past 25 years, because I've only personally observed a chunk of that time. I think we need to look to people who have actually observed these changes in order to know how far we’ve come. My guess is that we have made tons of progress. That clinicians’ understanding and use of research evidence today is far better than it was 25 years ago (anyone have good perspective on that?)
 
And I know from observing my peer SLPs that, for some people, the above strategies (those bullet points) actually work really well. They do know the research, or at least kind of do. And they know it because a) they’re passionate about it, and b) they’ve figured out how to reduce the barriers on their own. But those people are the minority. And a lot of them have unique personal experiences or advantages (e.g. they’re a clinical supervisor at a university, and thus get access to both the university’s library, where they can get all the research they want, plus access to faculty colleagues who support them along the way).

And when I say "we", like "we've tried x, y, and z", I'm genuinely including myself, here. Because you'll see me do the things, above. I can look back at social media posts I made 6 months ago, and cringe because it fits into one of those bullet points. I don't know if I do it because it's what's been modeled to me, or if it's just too hard to break out of that pattern. Or maybe because I just forget? Forget what it feels like to be standing behind the barriers? And that's tricky, because the people who know the research the best are the people who know the barriers the least. For us research-lovers, who have access to university libraries and eat science for breakfast, it can be really easy to forget how insurmountable the barriers can be because they're not barriers to us. 

Flash forward to present day:

Whether you think the the above strategies are good, bad, neither, necessary, whatever... it doesn't really matter. What matters is this: we do know they're not good enough. Because lots of SLPs still don’t look toward the research when engaging in clinical problem-solving.

And I think we can take this a step further, too. Not only is what we've tried to-date not good enough, but we're also doing some things that actually make the situation worse. And they all center around communication and relationships (now how a bunch of people who are supposed to be good at this can't seem to figure this out is beyond me...)
 
And that’s the purpose of this blog post—to talk about the things we’re doing wrong, right now. 
 
And let me preface by saying—these things tend to happen when large groups of SLPs get together—so on social media and at conferences. I really haven't seen any of it, personally, in small groups of SLPs working together (e.g. at school districts or in private practices I’ve worked at). Why? My best guess is because small groups of SLPs prioritize relationships, and working harmoniously (hold that thought in your mind for a moment...)
 
So here are what I see to be some of our current biggest screw-ups:
 
Blame, shame, guilt, and avoidance

The way our field has approached EBP has been consistently and subtly blaming clinicians.

Woah—that's an awkward thing to say! And yucky feeling. But hear me out.

Now, seriously—think about it. Answer this: “Whose fault is it that not enough of our research is implemented in clinical practice?” Who is typically blamed?

Whose fault is it?

OK, there. Now you're seeing it... Clinicians. The blame is almost always focused on clinicians.

Now, try to actually sit with the question a bit longer—“Whose fault is it that not enough of our research is implemented in clinical practice?” Could it be possible that it’s actually everyone’s faults? This includes: scientists, leadership, and business owners, in addition to clinicians. (And there are a TON of external factors at play here, too. But I’m talking about US. That is, the people who attend our SLP conferences and interact with our field on a daily basis. Let’s start by looking at ourselves, before we try to change the rest of the world.)

Let’s look at that list again:

• Clinicians
• Scientists
• Business Owners (large companies to small, from CEUs to therapy tools)
• Leadership (both at the state and national level)

… are all part of both the problem and the solution. We all have a role to play if we care about fast-tracking our best-available research data into clinical practice. I think, to date, we’ve screwed up by putting too heavy a burden on clinicians. This has been perceived by many clinicians as blame and shame… which then morphs into guilt (“Man, everybody tells me I should know the research, but it’s just so hard… Am I lazy? Am I dumb?”)… which then results in avoidance (“Forget this. I have clients to treat.”) Put simply, nobody likes to be made to feel bad about the work they’re doing. And it is hard to entirely avoid that (because, after all, how do you grow without identifying areas of needed growth?). But in general, the blame game is gross, rude, ineffective, and inaccurate when aimed squarely at clinicians.
 
How do we fix this? By acknowledging what all of us need to do.

Wait, no, stop. Forget that. That's not where you start, at all.

Where you start is with communication. Start by asking what people need. And don't ask your BFFs who are basically clones of yourself. Ask someone who occupies a totally different corner of our field than you do. And LISTEN. Listen, listen, listen. Ensure everyone’s voices and barriers are genuinely heard before you start guessing at how (and if) you should chip in. 

Then! Then, and only then, can you figure out what you need to do. Again: until you understand what everyone else's barriers are, you can't know what you need to do to help. And when you skip this step, you end up "helping" by simply doing things that work well for you.

That's how we avoid the shame game too—because if you understood, you wouldn't shame.

NOTE: I actually don't think solving the research-to-practice gap is everyone's job. Some people (e.g. certain scientists, certain business owners) have entirely different problems they're working on, and that's ok. But do note that the gap is still a problem. And if the gap is still a problem, it means more people need to get involved, and in ways that haven't been done before. If you're reading this at all, there's a good chance that you're someone who should be getting involved, and already are involved ;) So cheers to you!
 
Now onto the flame wars that are making it even worse.
 
Using journal articles as weapons

So this is something that is really damaging when it happens among large groups of SLPs—so on social media (mostly) and in conference presentations (occasionally).
What I’m talking about is when people use journal articles as a way to prove that they are correct, and someone else is shamefully incorrect. (This is, like, the foundation of academia though, #amiright!? So it often doesn’t even feel weird to scientists...) And for the most part, this is the way it’s supposed to work—you use data to guide your work. You use data to help you change your mind, and eliminate prior false beliefs and adopt a more accurate view of things. I mean, this is what advancement looks like, right! This is what knowing things looks like, right? Logically, this is the way things are supposed to work.

But here’s where it can go wrong—when people who know the research well (the small minority) use journal articles as a way to demonstrate that they know the correct answer, and the SLP who’s providing clinical practice data, or an opinion (even if based upon years of thoughtful practice) is the ninny who knows nothing.
 
And some of you will be like: “Yeah, so what? Data rules! Are you kidding me?! We have to use data to prove people wrong!”
 
And, yes… but here's the thing. If you don't consider facts along with people's feelings, your data is useless. Nobody gives a sh*t about it. Because you've trampled over their self-worth in an attempt to prove a point. So from a standpoint of preserving relationships, can you see how this is a really a**holey thing to do? Can you see how, from the perspective of an SLP, a single experience where someone uses a journal article as a way to aggressively win an argument, it you could actually turn that SLP off from research? Can you see how this interaction, if observed by many people, makes the aggressor look a) perhaps right, but also, b) like a total jerk.
 
And that’s the problem. We have to be really cautious about that, because it destroys clinicians’ relationship with the research evidence. Aggressive interactions among people in our field where journal articles are used as weapons in the argument casts a negative shadow on our science. It associates our science with the aggressor, and people tend to hold that association in their minds, logical or not. Thus, science lovers = total jerks. And that’s really damaging if we're trying to close the research-to-practice gap. It happens a LOT on social media, especially Facebook and Twitter. (I haven’t seen this hardly at all on Instagram, thank goodness. And if any of you try to bring that crap over to IG, I’m fighting you off—with a journal article on behavioral psychology, lol.)
 
So, in sum: subtle shaming (by many) + aggressive behavior (by some) = SLPs running away from the research as fast as their feet will take them. 

Don’t believe me that this is a major problem? Read here and here. Our science is being used as a weapon in crazy social media flame wars. The nickname some of these tribes of people have picked up is "evidence evangelists". 

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How do we fix this?  Hey, this one’s much easier! Don’t be a jerk with our science. I mean, really—it’s as simple as that. If you’re a heavy research sharer, be careful that you’re not coming across as aggressive or self-righteous. And when you see someone trying to use science to shame a clinician, step in. Remove the a**hole, keep the science.
 
So where do we go from here?

I don’t know, guys. I mean—it’s taken me two years of thorough observation just to start to see where some of the problems lie. And these issues are complex. "Be nice and listen" is a really good place to start, but it isn't that simple. For example, should you still "be nice" when someone is spouting claims for a product that doesn't align with the evidence and could be harmful to our clients? Yes. But that can quickly become difficult to uphold, because what's best for our clients is a lot more important than an individual person's feelings. So, what then? I'm telling you, it's not easy...

But my post isn't about the crazy character selling "Speech Vitamins".  Don't ask; no, they don't work. This post is about us. Clinicians, scientists, leadership, and businesses within the speech–language pathology space. It's about how we treat each other when it comes to EBP. And this post does have a particular focus on those of us who are EBP advocates. Why? Because we're the ones setting the tone, here. And, strangely enough, sometimes I think we're the ones who are screwing it up the worst.

So here's what I propose we chew on:

Clinicians do need to know the evidence. It’s what’s in their best interest and their clients’ best interest. But if you push that the wrong way—in a way that makes you seem out of touch with clinical reality, or in a way that over-burdens clinicians—not only does the message fall flat, but it can actually cause clinicians to move further from the evidence, because it reinforces their perception that the research doesn’t align with their needs. The solution isn’t pulling back on pushing the research, but instead sharing the research in a way that benefits clinicians. Let me say that again: in a way that benefits clinicians. Not in a way that's convenient for the message-giver. And that’s what really hasn’t been done enough to-date. Ultimately, what clinicians need matters the most. They’re the ones doing the lion’s share of work in our field.
 
So Step 1 = Listen to people. In particular, listen to SLPs.
 
Then Step 2 = a nice, easy, actionable item!
 
Don’t
be
a
jerk
with
our
science.
 
Seriously. Clinicians are #overit.

Written by Meredith Harold, PhD, CCC-SLP