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Elizabeth Usher Memorial Award Lecture How do we change our clinical practice? @tricmc.

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Presentation on theme: "Elizabeth Usher Memorial Award Lecture How do we change our clinical practice? @tricmc."— Presentation transcript:

1 Elizabeth Usher Memorial Award Lecture How do we change our clinical practice?
@tricmc

2 Thank-you & Acknowledgements
Cadigal and Wangal people of the Eora nation The University of Sydney Team especially Kirrie Ballard, Michelle Lincoln & Leanne Togher The USYD CAS research team especially Elizabeth Murray, Donna Thomas, Maryane Gomez, Jacqui McKechnie, Jacqui Lim, Cate Madill, Alison Purcell & all our honours students, interns and student clinicians Local and international collaborators Funding from CASANA & Ian Potter Foundation

3 Overview 2030 Vision – how do we move towards our vision
Evidence for treatments of Childhood Apraxia of Speech Why we follow the evidence (or why not) How science can help us understand our behaviour Nudging us towards our better selves and how science might help us achieve our vision.

4

5 Speech Pathology 2030: A positive scenario
All speech pathologists confidently and consistently use and contribute to the rapidly growing evidence base.

6 Speech Pathology 2030: a negative scenario
The evidence was available but speech pathologists did not have easy access to the literature; or found it difficult to interpret, synthesise and apply the evidence to individual clients. These services continued with outdated approaches and ultimately only attracted clients not well equipped to scrutinise what was delivered. Outcomes were poor. Word of services not making a difference was quick to spread. This affected the reputation of the individual clinicians.

7 What is the evidence in treatment of childhood apraxia of speech?

8 Research evidence for treating CAS
Cochrane Systematic review (Morgan & Vogel, 2008) AIM: To assess the efficacy of intervention for developmental apraxia of speech / developmental verbal dyspraxia. Types of studies: Randomised controlled trial (RCT) studies and quasi-randomised study designs. Types of participants: Children aged 3-16 years with CAS OUTCOME: No high level evidence for any treatment In any disorder the best research available should be captured by a well described systematic review. However Morgan and Vogel found no papers which met the inclusion criteria. So what then?

9 Murray, McCabe & Ballard 2014
Systematic review of lower level evidence examined … Diagnostic confidence Level of evidence Maintenance and generalisation Reliability and fidelity Independent replication Murray, E., McCabe, P. & Ballard, K.J. (2014). A review of treatment outcomes for children with Childhood Apraxia of Speech. American Journal of Speech-Language Pathology 23,

10 You can confidently use
Dynamic Temporal and Tactile Cueing (DTTC) Less confidence but possible Biofeedback Integrated Phonological Awareness (IPA) Ultrasound EPG Prompt Nuffield Dyspraxia Program (NDP3) AAC Melodic Intonation Therapy Rapid Syllable Transition Treatment (ReST) Motor Speech Intervention Combinations variously of MIT, Nuffield, EPG, Core Vocabulary Murray, McCabe & Ballard 2014, Maas, Gildersleeve-Neumann, Jakielski, & Stoeckel, 2014

11 Rapid Syllable Transition Treatment ReST

12 Outline of ReST research program
Year Project Paper 2007 Pilot - 7 children (Phase 1) McCabe & Ballard 2008 2008 Pilot - 3 chn (Phase 2) Ballard, et al 2010 JSLHR 2009 Typically developing children (Phase 1) van Rees et al 2012 AJSLP Pilot of orthographic stim - 4 chn (Phase 1) McCabe et al Dev Neuro-rehab Randomised Control Trial Rest vs. NDP3 – 26 children (Phase 3) Murray et al 2012 BMC Pediatrics; Murray et al JSLHR 2012 Reduced intensity ReST – 4 chn (Phase 2) Thomas et al JCD 2013 Parent training ReST – 4 chn (Phase 1) Thomas et al in press IJSLP 2014 Telehealth delivery ReST – 5 chn (Phase 2) Thomas et al 2016 IJLCD Copyright Dr Tricia McCabe, University of Sydney, June 2013

13 Other USYD CAS treatment research
RCT comparing ReST with Ultrasound Biofeedback with Jonathan Preston (Syracuse/ Haskins) DTTC parent training – Jacqui Lim PhD research Kaufman Speech to Language Program – Maryane Gomez PhD research Tabby talks – Tablet app for Nuffield Program – Jacqui McKechnie PhD research

14 Guilt – or true confessions of a researcher practitioner

15 What about other areas of practice?
So why do I feel guilty? Cognitive dissonance What about other areas of practice? Speech Sound Disorders more broadly McLeod & Baker 2014, Joffe & Pring 2008 Voice Disorders Chan, Madill & McCabe 2013 Signorelli, McCabe & Madill 2008 Stuttering O’Brian, Iverach, Jones, Onslow, Packman & Menzies 2013

16 Speech Pathologists are experts in behaviour change
So why would we find it hard to change our behaviour?

17 Meet Bill Why do I continue to drive a 1969 Kingswood when it is against my financial best interests?

18 Behavioural economics
A mix of experimental social psychology and economics Economics assumes people act as individuals and only in their own best interests but the data economists collect shows this is not true. People are weird: We make bad decisions all the time. Why is this the case and why is it important to you?

19 Israeli preschools Behavioural Economics explains this phenomena Reciprocity was broken by placing a value on the lateness Amon Tversky & Daniel Kahneman

20 Heuristic A cognitive shortcut or rule of thumb that simplifies decisions (Kahneman, 2003). We need shortcuts to function day-to-day but they de-rail us regularly. Heuristics can lead to cognitive biases. Some heuristics we all know – stereotypes, habits Others are less well known…

21 Some interesting heuristics
Social desirability Social norms Prospect theory Choice overload Loss aversion Endowment effect Sunk cost fallacy Status quo bias Anchoring Present bias Reciprocity Social proof Consistency Commitment Confirmation bias Overconfidence effect

22 Two systems of decision making
Automatic (fast & frugal) Reflective Characteristics Uncontrolled Controlled Effortless Effortful Emotional Deductive Fast Slow Unconscious Conscious Automatic = fast & frugal, relies on heuristics, ecologically rational Reflective = slow & considered, can supress heuristics, ecologically irrational Dolan, P., Hallsworth, M., Halpern, D., King, D. & Vlaev, I. (2010). MINDSPACE Institute for Government London Based on In the ‘fast and frugal’ view, the application of heuristics (e.g. the recognition heuristic) is an “ecologically rational” strategy that makes best use of the limited information available to individuals (Goldstein and Gigerenzer, 2002). Furthermore, while heuristics such as affect, availability, and representativeness have a general purpose character, others developed in social and consumer psychology are more domain-specific, examples of which include brand name, price, and scarcity heuristics (Shah & Oppenheimer, 2008).

23 Heuristic #2 Consistency or How to ignore Cognitive Dissonance
When our beliefs and our behaviour don’t match we feel uncomfortable – this is cognitive dissonance However we need to be consistent with our self image BE evidence – we rationalise the discomfort away rather than changing our behaviour

24 BE provides the solution: Commitment (Heuristic # 3)
Public pre-commitment to a future action has been shown to facilitate the required change

25 EBP through a behavioural economics lens

26 Surveys of clinicians about EBP say we
Value evidence Can find the literature Can interpret the results Have little time to search, read & digest the literature Don’t think our managers will allow us to change our practice Are worried we do not have the required time, training or resources to implement the research evidence  (O'Connor and Pettigrew 2009, Vallino-Napoli and Reilly 2004). – value EBP Skeat and Roddam (2010: 17) that within the allied health professions, survey methodologies often yield ‘positive perceptions of the principles of EBP’, while ‘studies that use more in-depth evaluation of … perceptions about EBP … have reported that staff expressed considerable uncertainties and reservations about how they were expected to be implementing these principles’. Foster, A., Worrall, L., Rose, M. and O'Halloran, R. (2015), ‘That doesn't translate’: the role of evidence-based practice in disempowering speech pathologists in acute aphasia management. INT J LANG COMMUN DISORD, 50: 547–563. doi: / O'Connor & Pettigrew 2009, Vallino-Napoli & Reilly 2004, Skeat & Roddam 2010

27 So a number of extraordinary clinical managers set up the world leading NSW Speech Pathology EBP network to help clinicians digest the research and therefore to implement EBP in their workplaces

28 and SpeechBITE was developed to help clinicians find the treatment evidence and to evaluate its quality – this was meant to save time

29 But … Social desirability bias (Heuristic #4)
the tendency of survey respondents to answer questions in a manner that will be viewed favourably by others. Leads to over-reporting "good” behaviour or under-reporting "bad“ behaviour.

30 Why don’t we do EBP? Cognitive dissonance means we feel bad about saying negative things, so we choose the socially desirable alternatives… Can find the literature Can interpret the results Have little time to search or read the literature Don’t think our managers will allow us to change our practice Are worried we do not have the required training or resources to implement the research evidence Skeat & Roddan, 2010; Foster, Worrall, Rose & O'Halloran, 2015

31 Why don’t we really do EBP?
I can’t be bothered “it aint broke, don’t fix it” I’m scared of change I don’t want to look like an idiot Its not a priority right now Cognitive dissonance means we feel bad about saying these things, so we choose the socially desirable alternatives.

32 EBP surveys that may be subject to social desirability bias …
Lim, McCabe & Purcell (2017). Challenges and solutions in speech-language pathology service delivery across Australia and Canada. European Journal for Person Centered Healthcare. 5 (1) Chan, Madill & McCabe (2013). The Implementation of Evidence-Based Practice in the Management of Functional Voice Disorders in Adults: A National Survey of Speech Language Pathologists. International Journal of Speech-Language Pathology. 15(3): 334–344 Signorelli, Madill & McCabe (2011). The Management of Vocal Fold Nodules in Children: A National Survey of Speech Language Pathologists. International Journal of Speech Language Pathology. 13(3): 227–238

33 But wait, maybe other heuristics can help us understand our EBP behaviour

34 Choice Overload or Overchoice Heuristic #5
Occurs when too many choices are available. More likely with a greater number or complexity of choices. Overchoice has been associated with unhappiness (Schwartz, 2004), going with the default option, and choice deferral—avoiding making a decision altogether, (Iyengar & Lepper, 2000). We also experience choice fatigue (Vohs et al., 2008)

35 Which car should replace Bill?
Small or large Hybrid, diesel, petrol, electric Sedan, hatch, wagon or 4WD Brand Inclusions Cost

36 Could overchoice be an issue in EBP?
Preschool stuttering vs. Phonological impairment Voice in Parkinson’s disease vs. Functional voice disorders Features of well accepted treatments Manualised, well researched, lots of resources Well promoted & controlled

37 What about overchoice elsewhere in SP?
Participants have a plethora of choices Inexperienced planners Likely result – ask for what you’ve always had (the default mode)

38 Solutions? Need to make navigating through the choices easier
Decision making tools for clinicians Shared clinician – client decision making tools Make one choice at a time The Mystery of the Haunted House, by Paul Channel Page 1 It is summertime again, vacation time. You go to your uncle's house. He takes you on a tour around the city. There are many old buildings, but the oldest of all is on Main Street. The address is 880. He says that it is haunted, but you don't believe him.  Choice: Do you go inside? (turn to page 2) Or: Do you stay there? (go to page 3)

39 Shared decision making aids – an example

40

41

42 Our ReST Shared Decision making tools

43 Clinician decision making tools
ReST clinician tool for step up- step down in therapy

44 Other people’s opinion & behaviour matters Heuristics #1, 6, 7
Reciprocity – Israeli preschool We react both more positively and more negatively than expected to other’s actions as a result. Social Norms – what other people are doing is impt The messenger is more important than the message Like me OR Highly credible

45 Pay your tax! UK Behavioural Insights (Nudge Unit)
Letters sent to non-payers You need to pay your tax by this date Only 10% of people like you have not paid their tax 90% of people like you have already paid their tax Which letter worked best? Other people’s behaviour is important to changing behaviour, we need to belong to a group. Heuristic #6 = Social Norms

46 How do we use this in our practice?
Public sharing of performance data NHS GP data Waiting lists, number of sessions, time to discharge Communities of practice Benchmarking Journal clubs Using messengers for change who are “like me”

47 What are our professional norms?
How do we un-blind ourselves to them?

48 Reluctance to change heuristics
Loss aversion (#8) Status Quo Bias and Inertia (#9) Sunk cost fallacy (#10) Endowment effect (#11)

49 How do we overcome these negative heuristics?
Inertia – reduce friction, make the best choice the easiest one e.g. High frequency therapy is default Plan to combat loss aversion – what will you lose by not changing / adopting this new practice Sunk cost fallacy & endowment effect?

50 ReST website examples Other SP examples
Premade therapy materials to download – reduces sunk cost fallacy Other SP examples TBI Connect Australian Stuttering Research Centre – Camperdown Program

51 Our internal reference points bias our behaviour
Overconfidence – we believe we are better than we are, even when confronted with data (#12) Confirmation bias – we see what we expect to see (#13) Anchoring - the comparator counts (#14) Time discounting – things take longer than we imagine (#15) Present Bias – we would prefer $5 now to $50 later (#16)

52 ReST website example Premade therapy materials to download – reduces sunk cost fallacy

53 Behaviour change is hard for our patients and its hard for us
How can we use Behavioural Economics to help our profession, our practice and our patients change?

54 Or Behavioural Economics in Policy and Practice
The art of the nudge Or Behavioural Economics in Policy and Practice

55 Meet Bob Rabbits have no voices. They silently nudge with their noses to get you to do what they want. He’s a Nudge Unit I want to nudge the profession, our clients & our community

56 Nudge Units in Australian Government.

57 Example from NSW Nudge Unit (BIU)
St Vincent’s Hospital outpatients unit Reminder text messages Randomly selected pts to receive 1 of 8 versions 8k texts sent to 5k patients Looked at which one elicited least FTAs Spotlight on Health Results (nd) obtained from Downloaded 21 May 2017 ISBN

58 Text messages – which one worked? Why?

59 Patients who received this message were 20% more likely to attend their appointment than patients who received the control message (p = .03). People care about the specific cost of their no show, esp. when they know they are preventing a loss to the hospital or other patients. The BIU estimated if the message was sent out in all clinics likely cost savings = $67,000 per year at SVH. If SVH had the phone numbers of all patients, this would increase to $97,000. Spotlight on Health Results (nd) obtained from Downloaded 21 May 2017 ISBN

60 UK government “Nudge Unit”: Unemployment in London
Jobseekers report in on 5 job applications per week Randomised to status quo OR 5 future applications – where, when, how Concrete thinking about the future changed outcomes: Why? We like to follow our plans We need to commit to our future selves to make change

61 EAST Easy Attract Social Time
Reduce friction, make it easy to say yes, harder to say no Organ transplants Service delivery Attract Attention, messenger Don’t hide your light Social Other people’s behaviour is important Other people’s opinion is important Reciprocity Unspoken SP norms Time What we would choose for our future selves does not match the decisions we are making now Rewards need to be close to behaviour. We need to commit our future selves to an action EASY Reduce friction, make it easy to say yes and harder to say no, decrease length of forms & s, prefill in forms, use EMRs, offer opt out rather than opt in – organ donation example, change the default - dose of therapy might be amenable to this – “Two sessions per week for 4 weeks then opt back to 1 session per week if necessary – see how you go” – then the habit is formed … ATTRACT – gaining attention in the right way, who is the messenger, needs to be either high credibility or “someone like me”, too scary does not attract SOCIAL – what other people do is important to us even if we think it isn’t. What are our professional “norms” – the unspoken ones? What do we lie to ourselves about? False estimates of other people’s behaviour easily overwhelms evidence, social includes reciprocity – give something to the person and then ask them to make a commitment for change, info about others not doing the right thing reduces stigma making it more likely that the person will also not do the right thing, TIME – we are trapped in the present. What we would choose for our future selves does not match the decisions we are making now – so rewards need to be proximal to the behaviour.

62 How do we use these ideas in speech pathology research and practice?

63 What can researchers do?
Develop and evaluate decision making tools for clinicians and consumers Reduce the friction on adoption of new assessments and interventions Clinician manuals Video exemplars Treatment resources

64 What can managers do? Reduce friction, plan for loss aversion
Make the profession accountable – public sharing of performance data would be a good start PICI project Waiting lists, service restrictions Time to discharge EAST acronym

65 What can clinicians do? For ourselves For our patients
Directly focus on our own reactions to new ideas e.g. Loss aversion Sunk Cost Fallacy Use decision making tools For our patients Make default choices easy Use shared decision making tools Focus on concrete actions rather than previous achievements

66 Nudge yourself to achieve your goals
Step Details 1. Set a goal Choose the right goal – single goal, clear target & deadline, broken into manageable steps 2. Make a plan How you can make it simple for yourself to do what you want yourself to do. Use the default setting to your advantage - Turn the plan into habits Set a no cross rule for yourself. 3. Make a commitment In public, with a date and a numerical outcome. Find a “commitment referee,” someone willing to keep you on task (but not too close to you). Service, O. & Gallagher, R. (2017) Think Small. The Surprisingly Simple Ways to Reach Big Goals. London; Michael O’Mara Books.

67 Stick is about practicing with focus and effort.
4. Rewards Reward is about putting something meaningful at stake, using small rewards to build good habits. e.g. If you go to the gym, you’ll allow yourself to binge-watch your favourite TV show while working out - it’s called “temptation bundling”. You could attach a punishment instead of a reward! (using loss aversion in your favour) 5. Share Share is about asking for help, tapping into your social networks and then using group power. 6. Get regular feedback Weigh and measure. 7. Stick at it Stick is about practicing with focus and effort. It’s about testing and learning It’s about reflecting and celebrating success. Service, O. & Gallagher, R. (2017) Think Small. The Surprisingly Simple Ways to Reach Big Goals. London; Michael O’Mara Books.

68 Commit to your future self

69 E3BP Δ Delta is a letter of the Greek alphabet Delta symbolises change
E3BP should lead to change but we need to change with it.

70 Acknowledgements The ReST program comes from the work of a large number of people. Researchers include: Elizabeth Murray, Kirrie J. Ballard, Donna Thomas, Pippa Evans, Jeannie McDonald, Tamra Staples, Anita McDonald Da-Silva, Lauren van Rees, Lorrayne Bejjani, Zhi Yi Alison Kwok, Jonathan Preston, Rob Heard, Michelle Lincoln, Geraldine Bricker Katz, Joanne Arciuli and Don Robin. Research assistants, interns and student clinicians including: Loren Apokourastos, Lauren Bassil, Morin Beausoleil, Esra Biyik, Jenna Bloom, Lauren Brender, Kate Broome, Anita Calabrese, Elisa Calcopietro, Angelina Chua, Sarah Coventry, Lisa Clark, Olivia Crowe, Laura Crocco, Katy Fisher, Claire Formby, Jennifer Fortin, Alyssa Gearin, Ali Hammond, Sally Hanna, Samantha Hardy, Ashleigh Hillyer, Loren Holmes, Amie Jakimyszyn, Lucy Johnson, Leanne Katz, Caitlin Kelly, Melody Lam, Flora Lau, Angela Lowndes, Claire Layfield, Emily Li Wah Lim, Natalie Lloyd, Brianna Lorea, Ellie Marrone, Annie Mackenzie, Catherine Mason, Penny Mason, Sarah Masso, Jacqui McKechnie, Jessica McKeown, Anne McKenzie, Becca Medwin, Amy Mizzi, Melissa Ong, Lauren Osborne, Samantha Overton, Aimee-Kate Parkes, Kate Patten, Gemma Patterson, Megan Phillips, Alyssa Piper, Jemma Prag, Elizabeth Saa, Dominique Scholl, Phoebe Sim, Tara Takach, Jessica Tam, Jessica van der Leeden, Lauri Vinokur, Olivia Vun, Rhonda Wilson, Caitlin Winkelman, Emily Wu, and Katrina Wu. Clinicians who were brave enough to adopt ReST before the manual was published and who gave us valuable clinical insights. And of course the children and their families.

71 Thank you


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