PEN@10 Years: Past & Present Challenges and Future Opportunities for Dietitians
The Past 10 Years:
What do King Nebuchadnezzar, Johnny Depp and Archie Cochrane have in common? Where did we start to conceptualize the PEN® service, what were the drivers and important contributors and milestones in our PEN® journey? Where did 10 years go? It was my pleasure to share the podium with Judy Bauer and Sue Kellie representing Dietitians Association of Australia and the British Dietetic Association as we shared our reflections on where PEN® has been over the last 10 years at the recent Dietitians of Canada conference in Quebec City. Take a moment to listen to our fun video presentation about our first 10 years and the PEN® partnership’s growing reach and impact in dietetic communities around the world.
Present Challenges for Dietitians:
We’ve never seen a time when evidence has been more abundant. We’re deluged with guidance and not all of it is good quality and certainly much of it is inconsistent. We’ve also never seen so many crazy headlines promising so many ridiculous things about food and nutrition. Diverse information channels provide platforms for so many unqualified and celebrity experts with so many contradictory recommendations. This creates so much noise and confusion that the validity of all nutrition research is being questioned. Every day, all over the world, dietitians are being asked to comment on provocative media headlines, bust another crazy nutrition myth, or rule on contradictory recommendations from different clinical practice guidelines. To add to the challenge, many consumers of our advice have developed a taste for information via sound bytes or in 140 characters – certainly not the best vehicle for conveying the complexity or nuances of nutrition science.
As dietitians, we appreciate that knowledge builds, often slowly, and seldom in a straight line. The study of nutrition/diet and health outcomes is complex. The placebo effect is alive and well and it fools people every day into thinking that the diet, nutrient or natural health product they just tried made them feel better. And social media allows them to share this newfound wisdom with thousands of friends in an instant. And yet, as health professionals, we are expected to practice critical thinking and base our practice on evidence but to do so with a sense of immediacy that I’ll confess makes me feel somewhat desperate at times.
In addition to spending my days pouring through evidence, I also monitor a lot of professional blogs and social media groups. I am in awe of the diverse and complicated practice questions dietitians receive everyday. It’s also clear to me that there is not good evidence to answer some of the issues or questions dietitians face. Patients may present with a vague complaint or may have multiple diagnoses that complicate what evidence or guideline a dietitian might turn to. But despite these challenges, we still feel compelled to provide some helpful counsel to our clients - in these circumstances we draw from our foundational knowledge and available evidence, combined with our clinical judgment.
In their book Practice-based Evidence for Health Care: Clinical Mindlines (1), Gabbay and le May confirm how valuable trusted colleagues are as sources for helpful information. They observed first hand how personal networks of experts were critical to assisting practitioners with evaluating new information, especially when the new information challenges what they thought to be true.
I worry that in our desperation for a quick answer, we sometimes accept any answer
rather than the best answer; one based on thoughtful assessment and critical thinking. I’ve done it myself, grabbed at the nugget of information that perhaps confirms my belief without pausing to look for opposing evidence. Or I consulted only with colleagues whom I knew generally shared my views. Gabbay and le May urge practitioners to develop their skills or techniques to encourage rigourous, but respectful questioning and appraisal of the views put forward when we seek counsel from our personal networks. We need strategies to avoid groupthink or confirmation bias. We must restrain our tendencies to settle for any answer and be systematic in our search for the best answers. But we must be mindful of not being paralyzed into inaction while waiting for evidence that may never emerge.
Those of you that have used the PEN® knowledge database for a while may recognize this next citation. I was reminded of it as I scanned the PEN® archives to craft the PEN@10 presentation for the Dietitians of Canada conference. In his paper entitled Scientific Literacy: New Minds for a Changing World (2), Hurd lists desired competencies that he feels evidence-based practitioners must be able to do:
Distinguish
- evidence from propaganda (advertisement)
- probability from certainty
- data from assertions
- rational belief from superstitions
- science from folklore
This list of competencies still resonates for me today and I’d add that we must always be mindful that our own biases influence what we read, whom we turn to for advice and what we choose to believe to be true. This has made me reflect on my own style of sharing information. I’m renewing my commitment to colleagues that when I send out articles or research papers, I’m going to pause and provide a little analysis too:
- Does the paper reflect someone’s opinion or is it a systematic review of all the best information on the topic?
- Does the information describe an association or suggest a hypothetical mode of action or was the research designed to measure a cause and effect relationship?
- Were the studies large and what population did they look at?
- Were the results important (likely to have a significant effect on symptoms or health)?
- How does this fit with what we already know?
- Are there any risks associated with the intervention being proposed?
- And importantly, is this evidence ready for application to practice or do we need to wait to see if other research groups replicate it?
Future Opportunities for Dietitians:
One of the principle objectives of the PEN® Global partnership is to build capacity for dietitians to become evidence connoisseurs; helping them appreciate just what makes for best evidence, how to conduct critical appraisal of research and how to communicate their assessments in ways that are meaningful to their clients and stakeholders. In the coming year, the PEN® team will transition to incorporating the GRADE system into its critical appraisal approach. Many authoritative organizations around the world are moving to this grading system. We believe its adoption by the PEN® system will enhance the rigour and transparency of our guidance. The PEN® team will work closely with the Department of Clinical Epidemiology and Biostatistics at McMaster University to develop not only a GRADE implementation plan for the PEN® system but also a training program for dietitians to learn how to use and interpret this internationally recognized critical appraisal system.
In 2016 we will also launch a new responsive PEN® website. Among its many features will be a new approach to crafting our key practice points so they provide more detail on how to translate the evidence into practice. And, we’ll further explore the development of a PEN® app.
As we summed up in the
PEN@10 celebration, staying abreast of the latest and best practices in evidence-based practice, knowledge transfer and information technology remain primary goals for the PEN
® global partnership so we can ensure that future dietitians have cutting edge tools to support their practices.
We plan to engage
more global partners; inviting more national dietetic associations, universities and dietitians from around the world to join the PEN
® community. In this way, we ensure the sustainability of the service while providing a platform for dietitians to collaborate with colleagues around the world.
We want to encourage each of you to use PEN
® to enhance your critical thinking skills, raise your profile and to create opportunities for yourself as leaders in evidence-based nutrition practice. Use it to develop blogs and
media sound bytes, proposals, briefing notes, lectures and patient care. Use it to respond to
misinformation.
In short use it to make your job easier. Share your successes and challenges with the growing PEN Community. Come and be active participants in the growing PEN Community! We are stronger together.
References:
- Gabbay J, le May A. Practice-based Evidence for health care: clinical mindlines. London, Routledge, 2011
- Hurd PDH. Scientific Literacy: New Minds for a Changing. World. Science Education 1998, 82:407-416.
Cited in: Dawes M, Summerskill W, Glasziou P,
Cartabellotta A, Martin J, Hopayian K. Sicily statement on evidence-based practice. BMC Medical Education 2005, 5:1
Written by:
Jayne Thirsk RD, PhD, FDC
Director PEN: Practice-based Evidence in Nutrition®
Dietitians of Canada
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