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Bonnie Spring, PhD, ABPP
Evidence-Based Practice: New Learning Resources to "Mind the Gap"
London subway travelers are repeatedly urged to "Mind the Gap!" The message calls attention to the (often nontrivial) physical gulf between the station platform and the train floor. I now keep a "Mind the Gap" emblem on my computer screen. It reminds me that behavioral medicine needs to cross a comparably insidious gap: the one between what we know scientifically and what we apply in health care practice. A useful bridging resource will now appear on the SBM website in the form of free, on-line learning modules about how to apply evidence in practice.
The Gap Between Evidence and Practice
The Institute of Medicine (2001) describes the gap between research and practice as a chasm whose neglect harms us all. One often quoted statistic is that it takes an average of 17 years for new scientific discoveries to make their way into practice. And even by the end of that period, only 14% of research knowledge has been adopted (Balas & Boren, 2000). In the interim, while we wait for current practice to catch up with what should be the standard of care, the average American receives only 50% of recommended health care (McGlynn et al, 2003). Ample experience testifies that translation between research and practice does not happen spontaneously of its own accord. Closing the gap requires new learning, deliberate effort, and systemic supports.
Of many possible translational strategies, consensus exists about the merits of one. Evidence-based practice is endorsed by the Institute of Medicine and all major health professions as a cornerstone of research to practice translation (Greiner & Knebel, 2003). So what is evidence-based practice? Why does it matter? And what do we and our students need to know about it? Below I touch briefly upon each of these topics. I also take pleasure in pointing to more in-depth coverage made available for you and your students in three new on-line learning modules. These modules, sponsored by the multidisciplinary Council on Evidence Based Behavioral Practice (EBBP) and supported by NIH's Office of Behavioral and Social Science Research, will now live permanently on the SBM website, where they will continue to be upgraded by SBM members. The first three modules cover the evidence-based practice process, strategies in searching for evidence, and systematic evidence reviews. You can access these free modules at www.ebbp.org/training. Also, on Saturday April 25th at the Annual Meeting, I hope that many of you will be able to hear Council members discuss how they use the modules to teach evidence-based practice to students in public health (Ross Brownson), nursing (Robin Newhouse), medicine (Jason Satterfield), and psychology (Bonnie Spring). Forthcoming in 2010 will be two additional learning modules: one on critical appraisal and one on evidence-based decision-making. In an exciting new translational venture, practitioner members of SBM will collaborate on developing the decision-making module, attuning it to the practice context.
The Whence, What and Why of Evidence-Based Practice
The evidence-based practice movement first emerged in medicine (Sackett et al, 1996), and soon spread to nursing (Craig & Smyth, 2002), public health (Brownson et al, 2002), social work (Gibbs, 2003) and finally psychology (Norcross et al, 2008). The EBBP task force, representing all of these disciplines, defines evidence-based practice as involving the integration via decision-making of best available research evidence in combination with consideration of client or community characteristics and resources (Council for Training on Evidence-Based Behavioral Practice, 2008).
There are four compelling reasons why the evidence-based practice movement has taken hold. First and foremost is accountability: the clear need to apply health care dollars equitably and only on treatments of demonstrable worth. Accountability is reinforced by key features of evidence-based practice. These include an explicit implementation process, a system of recommended standards for appraising evidence, and resources for determining which practices to apply under what circumstances. Second, because all major health professions have adopted the evidence-based framework, the use of shared concepts, methods and vocabulary facilitates collaboration by diverse professionals on transciplinary teams. A third appeal is the infrastructure of research syntheses, synopses, and summaries that evidence-based practice provides. That infrastructure addresses the practitioner's Achilles heel: too much information, too little time. Dissemination of systematic reviews and other research syntheses provides useful, up-to-date, time-saving resources for busy practitioners. An incidental benefit is that the systematic review process identifies key gaps in knowledge. By highlighting important practical and basic science questions that need answering, the synthesizing process stimulates development of the evidence base. Finally, there is the undeniable appeal that evidence-based practice supports lifelong learning. If we researchers do our jobs well, the best evidence-based practices of 2020 will differ from those being taught in graduate schools in 2009. Evidence-based practice embodies a lifelong commitment to continually learning best practices and updating skills.
The How of Evidence-Based Practice
The new on-line learning modules introduce the "how" of evidence-based practice for behavioral scientists and practitioners. These initial materials are geared towards graduate student trainees and faculty. Their coverage balances content geared toward clinicians who work with individuals and content geared towards practitioners who work with communities or populations. Three modules are available: the evidence-based practice process, searching for evidence, and systematic reviews.
Evidence-Based Practice Process Module. This 60-minute experiential module is designed for trainees who are just learning to work with clients. The module offers the learner a choice of whether to work with an individual who wishes to quit smoking or a community that is concerned about a high prevalence of smoking among local youth. Ana Abrantes, PhD, from Brown University and Jennifer Kreslake, MPH, from Harvard School of Public Health were the driving forces behind creation of the clinical and public health cases, respectively. The learner works through the steps of the evidence-based practice process - Assess, Ask, Acquire, Appraise, Apply, Analyze and Adjust - with the client. The module is highly interactive. Mistakes are a necessary (and fun!) part of the learning process. The following are some comments from different students who took the module:
Search for Evidence Module. This 30 minute module offers an overview of how to acquire evidence. It is rich in information about things you probably once knew but forgot and other things you likely never knew. Many users especially appreciate learning about the extensive roster of databases relevant to behavioral scientists. Students commented:
Systematic Review Module. This 30 minute module offers a comprehensive introduction to systematic reviews. Topics covered include judging the quality of a review, how and why high-quality reviews can reach different conclusions, and steps in conducting a systematic review. Elizabeth O'Connor, PhD, an experienced systematic reviewer for the U.S. Preventive Services Task Force, authored this module. A comment by Gordon Guyatt, MD, who coined the phrase evidence-based medicine, pretty much says it all:
Continuing education credits will soon be available for each module. Please try them out yourself and introduce them to your students. All feedback is welcomed. Finally, let me extend an open invitation to any SBM member who has interest in partnering to create new EBBP learning modules. I look forward to hearing from you!
Balas, E.A. & Boren, S.A. (2000) Managing clinical knowledge for health care improvement. Yearbook of Medical Informatics. J. Van Bemmel & A.T. McCray (Eds) Stuttgart: Schattauer Verlagsgesellschaft mbH: 65-70
Brownson, R.C., Baker, E.A., Leet, T.L., & Gillespie, K.N. (2002) Evidence-Based Public Health. New York: Oxford University Press
Craig JV, Smyth RL. (2002) The Evidence-Based Practice Manual for Nurses. New York: Elsevier Health Sciences; 2002.
Council for Training in Evidence-Based Behavioral Practice (2008) White paper on Definition and Competencies for Evidence-Based Practice, September 2008.
Gibbs L. (2003) Evidence-Based Practice for the Helping Professions. Pacific Grove, CA: Brooks/Cole; 2003
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy of Science Press; 2001
Lenfant C. 2003. Clinical research to clinical practice-lost in translation? N. Engl. J. Med. 349:868-74
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, et al. 2003. The quality of health care delivered to adults in the United States. N. Engl. J. Med. 348:2635-45
Norcross, J.C., Hogan, T.P, & Koocher, G.P. (2008). Clinician's guide to evidence-based practices: Mental health and the addictions. New York: Oxford University Press
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS: Evidence based medicine: What it is and what it isn't. British Medical Journal. 1996, 312:71-72