How to Establish and Encouragean Evidence-Informed Massage Therapy

Practice Learn to overcome key obstacles: lack of

time, support, knowledge, and confidence.

West Coast College of Massage Therapy

July 13, 2008

Presented by: Bodhi Haraldsson, RMT

MTABC research department chair

What is Evidence-Based Medicine?“Evidence-based medicine is the integration of best

research evidence with clinical expertise and patient values”

- Sackett & Straus

Ask

Acquire

Appraise

Apply

Act & Assess

Patient dilemma

Principles of evidence-based

practice

Evidence alone does not decide – combine with otherknowledge and values

Hierarchy of evidence

Process of EBP

Skills for each of the 4 steps*

Formulate an answerable questionTrack down the best evidence Critically appraise the evidenceIndividualise, based clinical expertise and

patient concerns

Evaluate our effectiveness and efficiency – keep a record; improve the process

*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.

Six factors influence the uptake of innovations

Relative benefit – what’s in it for me?

(non)-Complexity – is it easy to learn?

Trialability – can I try it out easily?

Observability – can I see others do it?

Compatability – fit with ideas and work

Reinvention – can I adapt it to me?

Rogers, Diffusion of Innovations

1. Relative Benefit – what’s in it for me?• Evidence-Based Medicine can:

– Reduce reading by quality filters– Better management of patients– Relieve anxiety about uncertainty

2. Non-complexity – is it easy to use?• How can we simplify EBM?

3. Trialability – can I try it out?

• How can we make EBM easy to try?

Trialability: do 1 step and get help with othersFormulate an answerable questionTrack down the best evidence Critically appraise the evidenceIndividualise, based clinical expertise and

patient concerns

Evaluate our effectiveness and efficiency – keep a record; improve the process

*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.

3. Trialability – provide easy steps

Keep a paper question log

Answer a few important questions / week

Get help with searches

Simplify appraisal OR use pre-appraised topics

Focus on interpretation

We’ll peer into … • Asking answerable

questions for EBM

• Barriers to learning with our questions

• How to teach EBM with questions

• Have some fun!

Group Task

• Groups of 2 – 3

• Discuss >1 question from recent work

• Write it down

• Be ready to report to group

• Return in 2 minutes

Questions• …

• …

• …

10 Common Questions• Clinical findings

• Harm/etiology

• Differential diagnosis

• Manifestations

• Diagnostic tests

• Prognosis

• Therapy

• Prevention

• Experience, Meaning

• Learning

(Not exhaustive or mutually exclusive)

‘Background’ Questions• About the disorder, test, treatment, etc.

2 components:

a. Root* + Verb: “What causes …”

b. Condition: “Rheumatoid arthritis”

• * Who, What, Where, When, Why, How

‘Foreground’ Questions• About patient care decisions and actions

4 (or 3) components:

a. patient, problem, or population

b. intervention, exposure, or maneuver

c. comparison (if relevant)

d. clinical outcomes (including time horizon)

Background & Foreground

What Pushes Us … Toward• curiosity• Prove colleagues wrong• Keeps coming up• Risk of patient harm • Want to do better• Anxiety• Avoid litigation• Internet informed patient

AwayTimeWe already know the answerFatigueAccessInferiority complex-anxiety-

afraid of admitting knowledge gaps

CynicalLazinessLack of supportPrevious failure at searchingLack of resourcesNoone else does itFear of change

How does it feel … ?

To know an answer?

To NOT know an answer?

Emotions in Not KnowingReady to … Feeling Behaviors

Flee Fear LeaveInvisible

Fight Anger DisruptUndermine

Cry for help Distress Stop tryingBody stress

Withdraw Sadness InattentionDetachment

Emotions in Knowing• Satisfaction: Self image of “knower”

meets reality of “knew this”

• Curiosity: the wind in the sails

• Joy: knowing and/or learning brings benefits to others

• “Zero gravity” or “flow”: when learning engages the mind fully without self consciousness

The Real ‘Three R’s’ of Learning

• Resilient

• Reflective

• Resourceful

Group Task• Groups of 2 – 3

• Discuss >1 question you recognized

• Write it down

• Be ready to report to the group

• Return in 3 minutes

Questions• a

• b

• c

• d

• e

Teaching with Questions

• Recognize: your learners’ questions

• Select: which questions to pursue

• Guide: how to ask and answer

• Assess: how well & what to improve

Selecting QuestionsConsider:• What is illness?• What is role?• What are learning

needs?• What are

available resources?

Of these, select:

• Most urgent

• Most interesting

• Most feasible to answer

• Most likely to recur

FAQ: Why Bother? 1• Relevant to clinical

needs

• Relevant to learning needs

• Plan searches

• Recognize answers

• Awaken curiosity

• In teaching, improve comprehension

• In referral, improve communication

• Have some fun!

• Any evidence?

FAQ: How Long … ?• Proficient? Quickly

• Mastery? Lifetime

• Human expertise takes >10,000 hours, >10 years

→Deliberate practice

Questions: Take ‘Em Home

• Believe Q’s rule

• Q are chances to learn and to use evidence

• Recognize Q’s– Background– Foreground

• Select Q wisely

• Match to Resources

Acknowledgements

“There is nothing new under the sun”

These slides have been partially adapted from:• How do we nurture Evidence-Based Practice?

Paul Glasziou, Centre for Evidence Based Medicine, University of Oxford

• Teaching EBM With Learners’ Questions

W. Scott Richardson, M.D.