Healthy skepticism in clinical practice.

I’m a bit of a stargazer, so I was exited to learn that we would be able to see the International Space Station passing over the UK last Christmas.  My family and I stood outside in the cold and watched in wonder as what looked like a bright star majestically passed directly over our house.  A couple of days later another astronomy tweet did the rounds claiming that on January 4^th 2015 we would all experience some weightlessness due to an unusual planetary alignment in our solar system. Thanks to Phil Plait – astronomer and blogger, this claim was debunked shortly afterwards as being completely false (Plait, 2014).  This saved me from the social embarrassment of jumping up and down on January the 4^th yelling to the kids “can you feel it?” for no good reason! Aside from astronomy, however, Plait’s blog caused me to reflect on the importance of healthy skepticism within our profession.

What is skepticism?

A skeptic questions the truth or value of a claim.  Not to be confused with religious skepticism, scientific skepticism is fundamental to the advancement of knowledge.  A skeptic will endeavor to base beliefs on the accumulation of evidence and is prepared to modify beliefs in the light of new scientific findings.  It is also not the same as intelligence, Plait noted that intelligent people are sometimes taken in by false beliefs.  This is more likely if the belief is either widely held or championed by an authority figure.

In the workplace, effective skeptical practice does not stop with questions but seeks evidence to either support or reject assumptions.  This may result in a conclusion of ‘we don’t know yet’, but that is better than a false assumption that we do know.   

Why is skepticism important for speech and language therapists?

We might consider that a skeptical approach to our work is not so important, because we are already underpinned by evidence-based-practice.  Alternatively we may believe that we are already skeptical enough.  A skeptical approach to work, however, is needed more than ever for the following reasons:

1.  Professional integrity

A huge amount of information is now available at the click of a mouse.  I recently carried out  a google search using the search term ‘speech therapy’ and it yielded over 18.5 million results.  Not only is the quantity of this information overwhelming, much of it will not be reliable and clients may find a vast range of cod science and quackery surrounding their clinical need.  As a protected profession we are trusted as experts and our message should be reliable. New trends that overlap with our therapy practice emerge regularly that claim efficacy but are not grounded in adequate or reliable evidence (examples in my field of practice include brain gym and baby signing).  Some advice even extends to the ridiculous, with one speech therapy blog hosting a guest blogger promoting astrology for children with communication needs!  Whilst most practice does not extend into the realms of the ridiculous in this way, we do need to be aware of the grounds on which claims of efficacy are made.   As we know, no evidence of effectiveness is not the same as evidence of non-effectiveness and therapists are entitled to be open-minded about new initiatives.  We should, however, be aware of the level to which different approaches are evidence-based, and in turn be honest with clients about this.

2.  Myths and legends. 

We may be tempted to believe that we are no longer subjected to myths and legends as in times past, however, there are still many stories that abound concerning communication and language that need to be debunked.  Recent mainstream news articles in the UK have blamed forward-facing buggies and ipads for damaging child development.  Neither claim is underpinned by any evidence (for an analysis of the iPads article see this Guardian post, and for forward facing buggies read my blog here).  Whilst as a profession, we generally follow principles of evidence-based-practice it can be tempting to run with stories such as these because in doing so we can promote our own messages (for example, a carer-facing buggy promotes face to face interaction).  I believe we have a duty, however, to be more robust with our professional advice instead of dressing up our messages up in popular opinion.

3.  Conflicts of interest. 

Sources of evidence that we are presented with may be influenced by bias due to conflicts of interest.  These may be financial but may also be for other reasons.  For example, ‘investigator allegiance’ refers to a particular intervention being championed by one person, who may be seeking to enhance their own reputation (Bernstein-Ratner, 2006).   This, as well as other conflicts of interest may lead to a bias towards positive results in the literature, known as a positive publication bias. Aware of this bias, there is now an expectation that negative findings of evaluation studies or trials are published but this still does not routinely happen.  Ben Goldacre highlighted this issue very clearly in the case of drug trials in this talk.  We need to be aware that a similar bias may also occur in our own field of practice concerning trials of interventions.  As a profession, we need to keep up with these results too, so we are aware of what is likely not to work for clients as well as what is likely to work.  Loff (2011) highlighted that if evidence suggesting an intervention does not work is not shared then ineffective practice can continue, grow in popularity and become part of the folklore of the profession. As I stated earlier, myths that are widespread are more likely to be believed.

What should we be skeptical about?

Skepticism should not just be limited to questions concerning effective therapy approaches. Our profession can benefit if we question all aspects of our practice, from theory underpinning our decisions through to discharge planning.  We should even question assumptions about evidence-based practice itself.   As we all bring different perspectives, collective and constructive skepticism can help to move the profession forward.

How can we exercise healthy skepticism?

We can’t all be experts on everything, so it is important to be skeptical collectively.  Make the most of specialists and regularly update care pathways in line with recent evidence.  Clinical researchers are skeptics in practice, so if there is a research active clinician or a researcher in residence in your team, use them to inform the questions you ask and the way you go about answering your questions.  They should be aware of the most up to date guidelines that are in place to inform the quality and clinical relevance of evaluation studies and trials. 

As well as researchers, use the tools now available to support evidence based practice decision making, including the What Works Website, SpeechBite and the Evidence-Based Clinical Decision making tool (Joffe and Pagnamenta, 2014). How about a regular “What’s the evidence?” feature in the non peer reviewed professional magazines, such as the RCSLT's Bulletin, where different contributors write an analytical article on the current evidence for a particular therapy?

Another great source for collective skepticism and a way to keep in touch with evidence based practice is to maintain an active Twitter account.  As well as my Twitter account @clarrysmith there are many ,champions for evidence based practice in the Twittersphere.  These include, but are by no means limited to @vjoffe, @SusanEbbels, @deevybee, @lilacCourt, @avrilnicoll, @speech_woman and @BronwynHemsley, as well as professional networking and organisational Twitter handles, including The Cochrane Library, WeSpeechies and EBPChampion.  Twitter also enables me to maintain an international perspective.  As well as my own professional body, the RCSLT, I am also able to follow other speech and language therapy professional bodies such as ASHA and SpeechPathAus.  I appreciate I am probably preaching to the converted here, if you have read this blog then it may be because you're already on Twitter.  If you benefit from Twitter in the way that I do, however, why not share this blog or your message with your colleagues via email and spread the word.  The more clinicians we can network with via Twitter, the greater our collective wisdom.

Reflective practice and clinical supervision are opportunities for disciplined skeptical thinking.  Reflective practice is a great opportunity to question your own practice and assumptions.  Within group supervision healthy skeptical conversations can be encouraged at work.

Skepticism can be seen as a negative trait but if harnessed constructively, it can help us to grow as a profession.  As we experience more commissioning of services, a team that enables open and constructive skepticism supports staff in developing robust services that they are proud to deliver.

References:

BERNSTEIN-RATNER, N. 2006. Evidence-based practice: an examination of its ramifications for the practice of speech-language pathology. Lang Speech Hear Serv Sch, 37, 257-67.

JOFFE, V. & PAGNAMENTA, E. 2014. Evidence-based clinical decision making. RCSLT Bulletin. London: RCSLT.

LOF, G. L. 2011. Science-based practice and the speech-language pathologist. Int J Speech Lang Pathol, 13, 189-96.

PLAIT, P. 2014. No, a planetary allignment on 4th January 2015 won't decrease gravity. Bad Astronomy [Online]. Available from: http://www.slate.com/blogs/bad_astronomy/2014/12/24/zero_g_day_nope.html [Accessed December 2014 2014].