Knowledge exchange in dental practice

Knowledge exchange in dental practice

My DPhil research out here at Oxford has taken me into (for me) some fascinating literature about the nature of knowledge and research. Having begun with what I now realise was a naive question - how to help clinicians practice more evidence-based dentistry - I have moved towards trying to understand better how research knowledge does or could fit in alongside (or blend with) the many other sources of knowledge that we all employ in our daily decision-making.

What is knowledge?

But first, what do I mean by knowledge? Here are a couple of definitions that inform my broad concept of knowledge:

• Collation of information for a particular purpose, intended to be useful (Sensky 2002)

• Facts, information, and skills acquired through experience or education (Oxford Dictionaries)

• Awareness or familiarity gained by experience of a fact or situation (Oxford Dictionaries)

Research is one form of explicit or codified knowledge. The research may be quantitative or qualitative and be assessed as robust or not, and relevant or not. But what Polanyi and Nonaka (and others) suggested is that this explicit knowledge first requires tacit knowledge. We don't consciously sit down and appraise what we know or don't know unless, perhaps, we're sitting an exam and realise we can or can't answer a question. Instead we perceive that we need to find out about something before we realise we need to know about X. 

Nonaka suggested that we externalise our tacit knowledge using metaphors or stories, combine that explicit knowledge with other sources of information (perhaps a colleague's experiences or some research), then we internalise it, making our own sense of the combined information and using it in a way that we may find difficult to describe. 

This is in keeping with other theories - particularly adult learning theories - that recognise we are not empty buckets waiting to be filled with knowledge but individuals with rich experiences who absorb, adapt, reject, or accept then reject new knowledge.

Gabbay and Le May found that General Medical Practitioners in a "good" practice used many other sources of knowledge than just research to make patient-centred decisions. Those other sources included colleagues, opinion leaders, their own experience, sales reps and patients. Estabrooks (2005) found that the majority of time nurses learnt their clinical practice knowledge from social interactions and experience, with a very small component coming from consulting research.

What influences knowledge use?

From personal experience this is not surprising. But if we think that research use is likely to be beneficial to patients then we may need to understand better the existing ways in which knowledge is taken up and exchanged. My reading has now included several traditions outside of the healthcare literature. Here are some examples of what they think influences explicit or research knowledge use:

From healthcare literature:

• Context
• Nature of the knowledge
• Process of knowledge exchange

From management literature:

• Professional boundaries
• Organisational learning (including tacit learning)

From economics

• Competition for the potential user’s time / attention

From psychology

• Individual behaviour and motivation

What to do?

The way in which knowledge is used is probably a lot more chaotic than many in the EBD/EBM world would like to think. This is where I began my DPhil - thinking that I could develop some kind of intervention to help dentists use research more in the traditional linear approach - ask, find, search... But now I realise we don't understand enough of how knowledge is exchanged within the primary dental care world, and how the mechanisms that allow other sorts of knowledge to move about might be used to help research knowledge do the same. 

And so I move on to study how and why given contexts and mechanisms influence dentists' uptake of knowledge before trying to help them use research with all their other knowledge sources.

References

Oxford Dictionaries: http://www.oxforddictionaries.com/definition/english/knowledge

Estabrooks, C. A., Rutakumwa, W., O’Leary, K. A., Profetto-McGrath, J., Milner, M., Levers, M. J., & Scott-Findlay, S. (2005). Sources of practice knowledge among nurses. Qualitative health research, 15(4), 460-476.

Polanyi, M., & Sen, A. (1983). The tacit dimension (pp. 21-25). Gloucester, MA: Peter Smith.

Sensky T. Advances in Psychiatric Treatment. 2002 September 1, 2002;8(5):387-95

Time to stop wasting data: The Clinical Practice Research Datalink

Let's stop wasting data

I was speaking at an event last night for general dental practitioners who are involved with, or interested in joining, studies in dental practice. One of my fellow speakers was a very engaging speaker called John Parkinson, who is director of the The Clinical Practice Research Datalink (CPRD) about which I will speak a little later.

Diagnostic codes

A little while ago I blogged about how useful it would be if dental electronic health records were to incorporate diagnostic codes to allow tracking of patient outcomes over time. The potential to observe the success or otherwise of patient management could be huge. Not only could we observe outcomes to routine treatment but potentially also conduct trials in practice using the codes to track what problems patients arrive with, any interventions we randomise them to, and the outcome.

So, for example, one of the audience last night asked the question: in a time-restricted environment is it better to provide oral hygiene advice or do a quick scale and polish, presumably for a patient with gingivitis rather than destructive periodontal disease. Well, using the SNOMED codes that I blogged about at the first encounter a dentist would record the following from a drop down box in the patient's record:

Code 66383009 Gingivitis (disorder)

Then the clinician records how it was managed. This could be as part of a randomised controlled trial - half patients are randomly allocated to scale and polish, half to oral hygiene instruction:

Code 234696006 Scale and polish teeth (procedure)

or: 

Code 58707002 Oral hygiene education (procedure)

Then, at the next visit the dentist, hygienist or therapist records whether gingivitis is present using the same code:

Code 66383009 Gingivitis (disorder)

If this data - that we probably record for thousands of patients every day anyway - were collected in this organised way then there would be a massive amount of potentially really useful data that we could use to answer the question asked by our colleague last night.

Clinical Practice Research Datalink

This is where the The Clinical Practice Research Datalink comes in. John Parkinson already churns the numbers for general medical practices using data from the last 25 years. What they can now do is to identify potential participants in research based on their medical conditions and create a pop-up that asks the clinician to ask the patient if they would be happy to take part in a trial. If the patient consents then they are randomised automatically to one treatment or another.

So imagine this as a dentist participating in a trial to find out whether you should give oral hygiene advice or a scale and polish in your short appointment: 

• a patient attends for a dental examination. You diagnose gingivitis and click the appropriate code (as above). 
• A pop-up screen asks you to ask the patient if they would like to participate in the trial. They consent and you click the appropriate button.
• The pop-up then tells you that for this patient you should give oral hygiene advice. So that's what you do.
• Then you see the patient again in 6 weeks / 6 months / 12 months and without even having to think about the trial you just record what you see. If there's gingivitis then you record it. If there isn't you don't.
• The number crunchers process the data and in a year or two we have a massive data set that allows us with some confidence to say whether one or the other is more effective when done alone.

So why aren't we doing this?

This effortless utilisation of information for the betterment of our patients is only likely to happen if we can get dental electronic health record systems to adopt the coding that enables us to track the problems patients present with, the interventions that we use, and the outcomes some time afterwards. John Parkinson wants CPRD to facilitate this - he just needs access to the data we have on our computers. And whilst this has generally been an NHS programme because GPs are almost all in it, it doesn't mean private colleagues without NHS contracts couldn't also be joining the network. 

The CPRD could also link our records to general health records. So potentially we could research whether, say, giving dietary advice in the dental clinic results in wider benefits to the patient - like reduction in obesity-related diseases, for example. And we could also track the outcomes of treatment completed in, for example, dental hospitals once they have been discharged back into the care of a general practitioner so allowing us to understand better the long term impact of hospital dental care.

As a dental profession I think we really need to join our medical colleagues and engage with this great opportunity and we need to start by persuading the dental systems to play ball. I don't know who the best people are to help with this...but perhaps you do.