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.

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 These services continued with outdated approaches and ultimately only attracted clients not well equipped to scrutinise what was delivered.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

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