“Be a discerning consumer of research” they said.
“Research can inform clinical practice” they said.
As summer is upon us and the social season is in full swing, I, like many of us, find myself in one of many social gatherings. Some are professional networking event and others are personal social events. While the people I interact with at these events are generally different folk, there are interestingly common threads that are unique to these events. For example, when people ask me what I do for a living and I reply that I am an academic at a university, they ask me if I am on holidays and how do I spend my three month-summer vacation (little do they realise that even though some students have finished, the academic year does not finish until late December – 23rd of December 2019). Another follow up question would be what does an academic do. I reply that in my role I teach and provide training for next generation of health care professionals, undertake and disseminate research which target challenges confronting the health system specifically and the community more broadly and engage with and promote to the wider community and stakeholders the outcomes of and impact from my work.
By this time, I am sure some folk regret their decision to engage with me but mostly this is then followed up by this question – “what do you teach?” I respond enthusiastically by saying “Evidence-Based Practice and Research”. Over the course of many years, I have been able to narrow down into three categories what happens next: Approximately 30% of people would say something like “interesting”, “good for you”, “well, someone has to do it” or any other variations and change topic (mostly about the dodgy weather); approximately 50% people would say something like “you are still teaching it”, “it doesn’t work in the real world”, “why don’t you teach students this X technique instead”, “how is the view of the world from sitting in the ivory tower” (I must confess – this mostly comes from my mates) or any other variations; and finally the 20% show some interest and follow up with more questions.
So, not surprisingly, a similar turn of events occurred at a recent professional networking event which featured several of my peers, including many I have known for several years. So, when questions such as “you are still teaching it”, “it doesn’t work in the real world” came thick and fast, I persevered and this time it was my turn to ask questions. So, why so much angst about Evidence-Based Practice (EBP) and research? I pointed out the value EBP and research as it is abundantly clear that what we do in clinical practice is not always based on current evidence or contemporary research. For example, the overuse of imaging for acute low back pain despite imaging having no diagnostic value or the provision of arthroscopy for knee osteoarthritis despite its lack of effectiveness or the misuse antibiotics for the common cold. I highlighted that these were merely a handful of evidence-practice gaps that confront our health system and communities and we, as health care stakeholders, need to do more to close these gaps.
Why not engage with EBP and research?
Well, the flood gates opened, and I got to hear their first-hand account of the issues that confront clinicians when engaging with EBP and research. There were several issues to successfully engaging with EBP and research, beginning with the research itself. Research often was conflicting, contradictory or confusing and when clinicians tried to engage it, it was not in a consumable form. They didn’t have anyone to help or mentor them to “unpack” what the research was about. When clinicians did want to engage with research, there were limitations in terms of accessing research as many did not have expensive subscriptions or they did not know who to approach to ask for help. Many clinicians had great ideas and wanted to partner with researchers to solve important health issues. But when they did engage with researchers, they were confronted with administrative barriers (such as intellectual property), procedural issues (ethics) and unrealistic timelines (many months or even years, if the project was to be undertaken as a higher degrees research). All this consumed the very little time clinicians did have outside of their busy clinical practice, and given it was the case of “once bitten, twice shy”, they were reluctant engage with EBP and research.
How can we overcome these barriers?
As the saying goes “for every complex problem, there is a solution, that is plain, simple and wrong” and therefore, it is important to acknowledge that this is a complex problem which will require concerted efforts and long-term thinking. However, there are some immediate and short-term strategies that can be readily implemented to tackle some of these barriers.
Given the quantity and quality of research output is increasing every day, the knowledge base will continue to evolve. How could a clinician keep up with research in a timely and efficient manner? There are a number of resources such as PEDro, OT Seeker, Cochrane Library, UpToDate which provides access to summarised and synthesised research information. For example, PEDro and OT Seeker are databases that contain abstracts of thousands of systematic reviews, randomised controlled trials and other resources such as clinical practice guidelines relevant to Physiotherapy and Occupational Therapy interventions. The trials in PEDro and OT Seeker are assessed for quality which means clinicians can get ready access to high quality research evidence. Similarly, Cochrane Library is freely available to anyone in Australia and is a collection of databases that contain different types of high-quality, independent evidence to inform healthcare decision-making. UpToDate is an evidence-based clinical resource which has a focus on point-of-care and contains literature and medical information. While PEDro, OT Seeker and Cochrane Library are free to use, UpToDate is a subscription-based service.
While these resources are useful and help to get the evidence at clinician’s finger tips, there are, however, some limitations as well. For example, PEDro and OT Seeker are discipline specific databases and as such may not include topics that may be of interest to all allied health disciplines. Furthermore, given that PEDro and OT Seeker provide access to summarised and synthesised research information, it may take a while before new and emerging research can be summarised and synthesised (as often this is undertaken by volunteers). So, what to do if you come across something interesting and want to know more? First and foremost, while it is tempting and may save you time and effort, don’t just read the abstract and make a decision about the research. Not all research is created equal and the abstract is merely a quick summary/ teaser about the research and the critical parts of the research are actually in the body of the research paper.
So, now that you know what NOT to do, what should you do in order to be discerning consumer of research? Well, perhaps you can use the following STRONG acronym to guide this process. People tell me (well, ok, my wife mostly), that I am a simple man and so acronyms such as this helps me to work through tricky concepts. Let’s start!
Verify where the research paper was published. Was it published in a reputable journal which has independent peer review or was it merely an opinion piece? Opinion pieces can be biased as it merely reflects the views of the author(s) and may not have any methodology underpinning it. On the other hand, peer review ensures there is an independent oversight of the research, although peer review too has some limitations. Increasingly many journals are moving to Open Access and as part of this, evidence of the peer review process, comments received from the reviewers and how it was responded to by the authors are all open for review by you as the reader.
Ask yourself “can I trust the research and its process?” In order to answer this question, look for information on whether the aims and objectives of the research align with the methods used in the research and conclusions stated, did the researchers obtain relevant ethics and organisational approvals, did the research follow best practice in the conduct and reporting of research (e.g. use of PRISMA checklist for systematic reviews, CONSORT for randomised controlled trials, STROBE for observational research, COREQ for qualitative research) etc.
Ask yourself “is this research relevant to me as a clinician?” In order to answer this question, look for information about details of intervention delivered (parameters such as intensity, duration, frequency, co-interventions etc), cost of the intervention, any extra training required to successfully implement the intervention etc. These are important issues to consider as it will have an impact on replicability of the intervention in your clinical practice setting.
Well conducted and scientifically sound research should be underpinned by research processes which are objective, robust and rigorous. There are a number of things you can look out for including, for example, the research should use reliable (repeatable) and valid (accurate) measurement process when collecting data to answer the research question, the research should ensure the researchers, knowingly or unknowingly, did not influence the results of the research (through strategies such as blinding), use of correct data analytical techniques etc.
Nothing but the truth
While many of us focus on the results of the research, as we want to know what new findings the research is reporting, equally important are the methods (what and how) of the research. If the methods are not robust and rigorous, then the results may not be credible and less trustworthy. Good research reporting is about being truthful and transparent about what occurred during the research process and how the researchers addressed any unexpected issues. For example, it is important to know how many participants were recruited at the start of the research (think about sample size), how many participants dropped out at various time points and how the researchers dealt with missing data. Some participants may have dropped out due to changed personal circumstances (such as unexpected move) but others may have dropped out due to adverse, or unexpected, outcomes from the research and this information should be acknowledged and reported.
Due to time, resource and practical issues, all research is focused on a sample of people (a subset from the wider population). We then have to take this information from the sample that participated in that research and extrapolate this to the wider population of interest. So, generalisability is about the extent to which research findings can be applied to settings other than where they were originally tested, such as to your patients and your practice context. When thinking about generalisability, the information you need are the aims of the research, which patients were included and excluded (inclusion/exclusion criteria) and why, how did the researchers select patients for the research (sampling framework), how many patients participated in the research (sample size) etc. For example, if you work in aged care and the research you have come across was conducted with 20 young adults recruited from the university where the research was undertaken, then the generalisability of the research findings to your practice context will be limited.
Ok, I know I am running out of time here, so couple more quick tips. If you do come across an interesting research article but you can’t access it as you don’t have subscription to the journal, what do you do? Well, PubMed (which is a pre-cursor to the famous Medline database) is free to use and search for that particular research article. When you find it, in the citation details, you will find the contact details of the author(s), usually in the form of an email. You can email the author and request a copy of that research article. Now, depending on copyright requirements, while they may not be able to share the final published version, they may be able to share the version that has been accepted by the journal (without the fancy formatting, colour images etc). Also, if you are interested in learning more about “how” to be a more discerning consumer of, and in your engagement with, research and evidence, the University of South Australia’s Library has a fantastic Evidence-Based Practice guide. Check it out!
Finally, thank you, Sarena, for giving me the opportunity to contribute to this awesome blog. We are strong when we work together and share our knowledge and expertise. To that end, I would love to hear from you and heck, I can even discuss about other things too (Star Wars – The Rise of Skywalker – yay, or nay – anyone?).
Associate Professor – University of South Australia & Physiotherapist
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