Submitted by Dr Jayne Thirsk, RD, PhD, FDC
Director, PEN, Dietitians of Canada
Social Life of Knowledge
Patients receive care based on the evidence only 55% of the time (1).
- ⅓ of patients do not get treatments of proven effectiveness.
- ¼ of patients get care that is not needed or is potentially harmful.
- Up to ¾ of patients do not get the information they need for decision-making (2).
Statistics like these, while perhaps discouraging, also prompt a call to action:
- That care provided to patients is grounded in the best available evidence.
- That strategies be developed to expedite and enhance the use of best evidence by health practitioners to ensure patients receive consistent care no matter where that care is provided (1).
And so, the terms evidence-based practice and knowledge transfer became part of our practice vocabulary. With this “PUSH” to be evidence-based practitioners came a “PUSH BACK” against the mindless application of evidence-based guidelines without thought to the uniqueness of each patient and the circumstances in which the care is provided.
To explore this issue in more detail, I recently purchased an online book entitled: Practice-based Evidence for Healthcare: Clinical Mindlines by John Gabbay and Andrée le May (3). The book examines how clinicians actually acquire and use their knowledge in practice. They explored this, both at an individual and group level, with the goal of strengthening the use of evidence in day-to-day practice. The illustrative vignettes that form a foundational piece of each chapter provided a “reality check” in terms of the barriers and challenges to adopting evidence into practice. Though mostly focused on a primary care service in the UK, the learnings have much broader application.
Gabbay and le May approach this dynamic tension between wanting to provide the best possible care by applying evidence-based guidelines and the realities of practice from many different angles. Drawing on the literature and their
ethnographic observations, they offer a number of explanations of why it can be so hard to get best evidence adopted into practice. Though the authors address many reasons for this, I’d like to focus on a couple that particularly resonated for me:
- Some types of decision-making may be particularly resistant to new evidence
- Evidence, though important, is only part of the decision-making picture and it must be viewed in context of the particular care situation
Some types of decision-making may be particularly resistant to new evidence
Gabbay and le May first describe how practitioners rely on a complex set of psychological processes and patterns of thinking that they call mindlines or mental maps to make many of the “quick” decisions they are required to as part of their day.
They define mindlines as
"internalized, collectively reinforced and often tacit guidelines that are informed by clinicians’ training, by their own and each other’s experience, by their interactions with their roles, by their reading, by the way they have learnt to handle the conflicting demands, by their understanding of local circumstances and systems, and by a host of other sources” (4).
Recall the example of taking a diet history described in:
Hunting, Foraging and Hot Synching Your Way to Better Decision-Making. My ability to conduct a diet history was grounded in my undergraduate training where I observed trainers performing the skill and then practiced it myself. My performance was evaluated and I incorporated the feedback received. It was enhanced over the years by watching colleagues, adjusting my techniques based on type of client or type of consultation and incorporating style elements based on my experiences of what worked. I just “know” how to get a diet history started and what questions to use to probe for more information. This is my “diet history mindline”.
Some of the typical inputs into mindlines that were identified by Gabbay and le May (3) include:
- Local norms /routines
- Role models’ behavior
- Institutional culture
- communication patterns or norms,
- group norms, values (customer focus, connection to community)
- social climate (degree of formality or informality )
- Trainer/teachers’ norms
- Peer values
- Guidelines (new research or evidence)
- Embedded science
- Heuristics [“common sense”, rules of thumb, or knowledge gained by experience]
- Technical skills
- Soft skills such as professionalism, ethics, cultural competence, reflective learning, use of humour)
- Practical skills such as communication, history taking etc.
- Tacit and experiential knowledge
Clearly, many of these inputs could be considered to be social in nature; relying on interactions with, or observations of peers, trainers or role models. Gabbay and le May make an important observation about this social element (3):
“ Before new knowledge can lead to a behavioural change, clinicians will actively relate it to what they and their trusted colleagues already, possibly implicitly and tacitly, know or believe. They will assess its relevance, benefits and disbenefits and in effect “negotiate” a final position in which they may or may not be persuaded to incorporate the new evidence into what they do. In short, for research evidence to inform practice, it must be subjected to a social process that continually and repeatedly transforms it from the explicit knowledge that emerges from the research works into something suitable for internalization as part of the mindlines, the “knowledge-in-practice-in-context that is used in the clinical world.”
So where does this leave evidence relative to practice decisions? Mindlines are NOT meant to discount the value of applying the very best evidence to one’s practice. To be effective, mindlines MUST also be flexible and constantly modified by new knowledge, evidence and changing practice circumstances. Mindlines must be regularly scrutinized through self-reflection (recall those
cognitive biases) and dialogue with peers; they must consider new practice realities and technological advancements and constantly be updated and informed by new, valid, important and applicable research evidence. And herein lies the challenge – what is the process that we, as dietitians, go through to update our mental maps or mindlines? How do we recognize all the factors that helped to create our first mental map, and yet, still update these mental maps with new evidence?
Evidence, though important, is only part of the decision-making picture and it must be viewed in context of the particular care situation.
Many types of evidence, knowledge and skills contribute to evidence-based decision-making. Patient values, experience and context are critical factors in determining what evidence or knowledge is needed at any given time to make the best practice decisions.
Some examples of “other” types of information or knowledge a dietitian might consider when making a practice decision:
- What the client or patient wants and needs.
- What the patient already knows/believes and the care they have received in the past.
- How best to establish rapport with the patient.
- How the patient perceives the Dietitian.
- What is the accepted way to manage any given condition? Why is it the agreed upon practice (i.e. what is the scientific rationale – is it established or hypothetical?)
- How reliable is the science?
- What are the “local” deviations from accepted practice and why?
- What are the “institutional” norms in providing care for this patient”
- Can the patient understand, afford, or manage the care plan I recommend?
- Are the relevant practice guidelines realistic and practical? Do they apply to my client?
- What are the risks vs. benefits vs. costs of various options of treatments?
- Do I have the knowledge and expertise to adequately care for this client? Where can I go to, to get expert help on this topic if I need to?
- Are there local consultants or services that might benefit my patient or that I could refer to?
- Who are the local opinion leaders in my area and how accessible and reliable are they?
- What are the relevant professional standards I am bound to by virtue of being a regulated health professional?
- If working in a group practice or on a team
- What are the skills and qualifications of others in the group or team?
- What is their capacity for work and how do they organize their practice?
- What aspects of care can I delegate to whom?
- How do my colleagues like their patients managed?
- How to I handle a situation where I disagree with patient management by a colleague?
- How to communicate many different types of things to many different types of people?
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Adapted from Box 3.1 Examples of what a GP needed to know during a typical surgery (3)
I recently provided a consultation for an individual navigating a low iodine diet prior to radioactive iodine (RAI) treatment for thyroid cancer post thyroidectomy. While familiar with the rationale for the diet, I had no recent experience with counseling patients on this diet. This individual was known to be quite meticulous and approached me with a plan to obsessively “eliminate every μg of iodine” in their diet. She had surfed the Internet and found the guidance contradictory and confusing. The individual was 84 years old and independently caring for her 96 year old husband in the community. A diet history revealed a well balanced diet generally low in sodium due to a previous consultation with a dietitian regarding hypertension management. Weight was stable and BMI was 25. Some of the things I considered prior to providing her with more general guidelines included:
I learned that expert opinion supports following a diet low (< 50ug I/day) for two weeks prior to RAI treatment in order to increase RAI uptake by remnant thyroid tissue. Adverse effects include possible radiation toxicity and hyponatremia.
Most nutrient databases don’t include iodine in the list of reported nutrients therefore accurate nutrient composition data is hard to find.
Iodized salt and foods prepared with it, fish/seafood and dairy products (due to iodine preparations used in sanitation) are major sources of iodine in the diet in Canada.
While fruits and vegetables can vary in their iodine content based on growing conditions, they are generally lower in iodine than most other food groups.
The client’s concerns about the diet were acknowledged and addressed and she was reminded that the goals of the diet were to reduce iodine consumption to less than approximately 50ug for two weeks rather than her intended plan of total elimination. She was encouraged not to be concerned about weighing and measuring her food during the low iodine diet phase. A simplified list of high iodine foods to avoid was provided. Non-iodized salt was discussed as an option and she was encouraged to discuss her risk of hyponatremia with her physician.
In providing care to this individual, I first determined what best practice was by consulting PEN. I then altered this evidence to consider:
- What the client already knows/believes.
- What the client wants and needs.
- Can the patient understand, afford or manage the care plan I recommend?
- Are the practice guidelines realistic and practical? Do they apply to my client?
- What are the risks/benefits and costs of the treatment?
- Do I have knowledge to adequately care for this patient? Where can I go to get more information or whom can I refer the patient to?
Practitioners are “science-using, information-sorting interpreters” (5) of situations and need to use their judgment to make informed decisions regarding the care they provide. As evidence-based decision-makers, dietitians must continually revise their existing knowledge with new evidence relevant to their client, the groups in which they practice and the institutions or organizations in which they work. In the context of dietetics, I might describe this as part of the “art” of evidence-based dietetics.
References
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Committee on Quality of Health Care in America. Washington DC. National Academies Press. 2001 [accessed 2013 May 27]. Available from: http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx
- Straus SE, Tetroe J, Graham ID, Leung E. Knowledge to Action: What It Is and What It Isn’t. Available from: http://www.cihr-irsc.gc.ca/e/40618.html
- John Gabbay and Andrée le May. Practice-based Evidence for Healthcare: Clinical Mindlines. New York, New York: Routledge; 2011.
- Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines”? Ethnographic study of knowledge management in primary Care. BMJ. 2004 [cited 2013 May 27];329:1013-16. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC524553/
- Montgomery K. How doctors think: clinical judgment and the practice of medicine. Oxford: Oxford University Press; 2006.
Glossary
Tacit knowledge:
intuitive knowledge or know how which is rooted in experience and practice. It resides in the mind of the practitioner and is hard to communicate. It is passed along through socialization and mentoring. As opposed to explicit knowledge which is codified knowledge found in documents and databases. From:
http://www.knowledge-management-tools.net/different-types-of-knowledge.html