This is the second in my promised series on the topic of Evidence Based Practice versus Patient Centred Care. I will respond to the implication that EBP constrains the choices of the patient and the SLP thus conflicting with PCC and minimizing the role of clinical expertise. I will argue that the evidence is less constraining than generally believed. The SLP must understand the general principles revealed by the research and understand the patient’s needs well enough to apply the evidence. As Sue Roulstone put it “Clinical expertise supports the skillful application of that research to the practice situation”.
It is necessary to know the research deeply in order to understand the clinical implications beyond the simple “what works” messages that might be found in the paper abstracts. I will provide two examples. Recently Françoise Brosseau Lapré and I published a randomized control trial (RCT) in which we reported that 2 of 4 interventions worked well (one focusing on intense speech practice and the other focusing on listening and responding to speech inputs). Both interventions involved 6 weeks of individualized speech therapy followed by a 6 week parent-education program. We have been talking about this trial in the local community for some time now and unfortunately the take away message seems to have been that parent training works. SLPs are using the trial as a justification for the implementation of parent training initiatives without an accompanying individualized therapy component. And yet, a careful reading of our work reveals that the trial is not, ultimately, about parent training at all. Our research was about alternative means for providing intense focused inputs to children with phonological disorders. In one way the results of the trial increased options for SLPs and families by showing that two approaches can be equally effective as shown in a previous blog post; at the same time the trial should constrain SLP choices somewhat by focusing attention on intensity and coherence in the selection of treatment procedures.
Another example is provided by the parent administered focus stimulation program for treatment of morphosyntax delays described by Marc Fey and Pat Cleave many years ago. They reported that a parent implemented intervention could be as effective as an SLP implemented intervention while being very efficient, requiring about half as much SLP time per child. I remember that shortly thereafter many SLP programs in Canada cut their ration from 16 to 8 weeks/hours per child and strongly promoted parent mediated interventions as the primary mode of care. The thing is that the parent program described in Fey’s trial required 21 hours per child to implement! Furthermore, a follow-up study revealed that parents were not able to implement it as effectively when their children’s goals became more complex.
There are many studies that involve parent implemented interventions and overall what they tell us is that (1) intensity matters – an effective speech and language interventions gets as much “data” to the child as possible; (2) parent involvement in the therapy program is just one way to achieve an increase in intensity; (3) parents can be effective if they are very well trained and supported and the home program is focused on the achievement of specific goals; (4) training and support takes time and effort on the part of the SLP; and (5) not all parents are equipped to implement speech therapy for all goals. There is a lot of nuance here and SLPs should be empowered to apply this research evidence to meet their clients’ needs.
I know that SLPs prefer to make decisions in the best of interests of their patients without being constrained by evidence based care guidelines. But the flipside of understanding the evidence well is understanding your patient’s needs equally well. When I was a young SLP, I know that I made many mistakes in this regard until I learned some things the hard way. I recall that when my daughter was small and needed a lot of therapies, the various providers fervently believed that it was best if I provide all those practice exercises at home in the natural environment. Furthermore, somebody, without consulting me, decided that a speech-language pathologist was not a necessary member of my daughter’s rehab team because I could fulfil that role myself! I ended up in the nurse coordinator’s office crying, ‘I am her mother, not her therapist’. Mercifully, a whole new plan was put in place. The thing is, that for PCC to work you have to really understand what the evidence says and then you have to understand the needs of your patients.
An excellent qualitative study that shows how breakdowns in PCC lead to poor outcomes is found in Annals of Family Medicine. The authors identify four archetypes of engagement in shared decision making (SDM): full engagement (SDM present, subjective experience positive); simulated engagement (SDM present, subjective experience negative); assumed engagement (SDM absent, subjective experience positive); and nonengagement (SDM absent, subjective experience negative). I strongly recommend reading the paper and the vignettes made available in the online supplemental material. They make for fascinating reading. Full engagement is characterized by shared decision making and mutual trust. The other situations often involve one or both parties making assumptions about the other person’s feelings or motives, leading to a lack of disclosure of important information.
The research evidence might tell you that an intervention can work. Patient centred care is necessary to make sure that it will work.
