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

Respecting tacit knowledge in knowledge transformation

I used the term knowledge transformation in the title of this blog instead of the common terms knowledge translation or knowledge implementation because, as Morgan Meyer and others have argued, knowledge is rarely used in its original sense.

In a previous blog I discussed Gabbay and Le May's work in general medical practices that led them to understand that doctors create their own "mindlines". I have also read more recently about the SECI model proposed by two Japanese researchers in the 1990s, Nonaka and Takeuchi. They were studying the creation of knowledge within commercial organisations and sought to include the tacit knowledge we all gain through doing and observing but which may be hard to explain, with the explicit knowledge shared through discussion and reading.

This latter model reinforces what Gabbay and Le May found, that doctors' knowledge developed not only through the use of explicit information in the form of guidelines but also the tacit knowledge gained through observing how each other worked and their own interactions with patients and people or organisations outside their practice.

The SECI model stands for: socialisation, externalisation, combination and internalisation. [The diagram here is reproduced from the Gabbay and Le May book].

The idea is that we learn tacit knowledge through a process of socialisation. This involves us observing others working. In an organisation where knowledge creation takes place, they argue, this tacit knowledge needs to be made explicit. This is done by individuals using metaphor and analogy to explain their experiential learning. In turn the externalised knowledge is combined with other information sources.

From my point of view, looking at how to help clinicians use research in decision-making, this includes using research but also using other information sources. The combined knowledge might then be expressed as a lecture, a practise protocol or a guideline generated from this process. Finally, we internalise the combined knowledge as we make sense of it and, if we use it, introduce it in some form into our practise.

Much of the knowledge translation world has ignored, it seems to me, not only the other sources of information that go into making a decision but also the tacit knowledge we all have that may never be expressible. If we take account of pre-existing knowledge - and value this as much as the scientific knowledge we gain - we take a constructivist philosophical view. If we take the view that only scientific knowledge gives us true knowledge then we take a positivist view.

I have moved progressively from the positivist to the constructivist over the last few months as I have learnt more about the way we actually function. It seems to me that even if we wanted to perform every activity according to a positivist stance that everything can be explained by some physical or social law, we would never succeed because we inherently value our own knowledge and experience.

Moving forward, my feeling is that if we - those interested in helping useful and appropriate research to be incorporated into clinical decision-making - are to serve any function then we need to  respect more the complex decision-making and knowledge creation that all clinicians (and human beings generally) are engaged with daily.

Mindlines and Evidence-Based Practice

When I began my DPhil at Oxford I proposed a research idea that would look at the system within which dentists work and develop an intervention to help increase the use of evidence-based practice. I was thinking of the now ubiquitous 5 stages of ask, search, appraise, apply, evaluate.

However useful these skills, though, I realised pretty early on in my reading that helping dentists to do this regularly would be extremely challenging - the barriers to using evidence-based practice have been well documented (e.g. Cabana, M. D. et al. 1999, Zwolsman, S. et al. 2012) and if one thinks at the organisational or systems level, the complexity of helping useful innovations get into daily practice can be immense (Greenhalgh, T. et al. 2004).

The implementation science research field tries to get knowledge into practice often using psychological and behavioural theory to inform (e.g. Michie, S. et al. 2005, Grol, R. P. et al. 2007). But something always felt a little like we as clinicians were being required to do something by a higher authority and somehow this didn't feel very democratic. To me someone trying to implement a set of externally-justified guidelines that I had little part in designing felt inappropriate. I realised that this might be framed not so much as democratic but perhaps as an affront to our individual clinical decision-making that, according to evidence-based practice principles, required that the best evidence be used alongside our own clinical expertise and the values, wishes and aspirations of our patients (Sackett, D. L. et al. 1996).

I then came across John Gabbay and Andree le May's work on what they termed mindlines (Gabbay, J. & le May, A. 2004). They published a report into a study in a couple of general medical practices in the UK where they observed how well-reputed clinicians made decisions. Very few referred to evidence-based guidelines in consultations with patients but rather, they observed, they built up their own flexible and constantly-moderated internal guidelines or "mindlines". These took into account not only the research evidence but the practical issues of applying it, their own experience of it, the views of trusted colleagues, the local services available, time, etc. The observed reality was that decision-making was largely influenced by tacit knowledge rather than the explicit, codified form delivered in guidelines.

The authors of that study published a book in 2011 (Gabbay, J. & le May, A. E. 2011) that describes the original and related work in detail but that deepens the discussion by looking at other research and theories. Fundamentally they conclude that "the assumptions of the EBP movement are misguided" by assuming that if we somehow put research knowledge into the clinical situation that it will be transferred into practice. They argue that one has to be aware of the complex social and psychological processes that need to be altered if one is to use more research in practice. They argue that the uptake of knowledge needs to be understood more at the social and organisational level rather than concentrating on the individual use of research evidence.

This book makes sense to me as a clinician and as a researcher. I recommend it as a great read for anyone involved in trying to facilitate the increased use of research in clinical decision-making. If you do read the book don't leave out the last chapter - it contains some excellent pointers on how we might further the research on helping clinicians and patients benefit from using research and non-research knowledge to improve care.

References

CABANA, M. D. et al. 1999. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA, 282, 1458-65.
GABBAY, J. & LE MAY, A. 2004. Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care. BMJ, 329, 1013.
GABBAY, J. & LE MAY, A. E. 2011. Practice-based evidence for healthcare : clinical mindlines, Abingdon, Routledge.
GREENHALGH, T. et al. 2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q, 82, 581-629.
GROL, R. P. et al. 2007. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q, 85, 93-138.
MICHIE, S. et al. 2005. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care, 14, 26-33.
SACKETT, D. L. et al. 1996. Evidence based medicine: what it is and what it isn't. BMJ, 312, 71-2.
ZWOLSMAN, S. et al. 2012. Barriers to GPs' use of evidence-based medicine: a systematic review. Br J Gen Pract, 62, e511-21.