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].

We need a positive culture of music for our children.

I originally wrote this commentary last year, inspired by the Channel 4 series "Don't Stop the Music". The comments are still valid but I have updated the blog very slightly. This year a fantastic project called TenPieces has been produced by the BBC, which aims to introduce primary school children to ten well known pieces of classical music in a dynamic and interactive way.  It's a great project and my son's school has been using it as a basis for music lessons with really positive outcomes.  My son has come home singing classical pieces he has learned and he also is able to talk about the composer and the structure of the music.  I experienced a real joy the other day when he commented "I really like classical music, in fact some of my favourite tunes are classical music!"

To find out more about Ten pieces click on this link, or follow #BBCTenPieces on Twitter.

Last year Channel 4 produced a short series called 'Don't stop the music', featuring James Rhodes, a concert pianist with a mission to revolutionise music teaching in Britain's Primary Schools.  You might be forgiven for thinking - 'oh no, not another mission campaign programme', following hot on the heels of the likes of the highly admirable Jamie Oliver, Hugh Fearnley Whittingstall and Gareth Malone, but perhaps yet another expert moralising about what we need?

After watching the series, however, James Rhodes appeared to have got this right. First, it is apparent that  the state and status of musical teaching in primary schools in the UK is dire.  As a developmental language therapist I've been banging on about this for years so James Rhodes is a man after my own heart.  Our children are currently being denied access to quality musical education in primary school - the early, formative years when it really matters.  And I believe the root of this problem lies with a lack of a positive musical culture in school and at home.

Why do we need to develop a culture for music?

Do you like music? - seems like a pretty stupid question doesn't it, because we all enjoy some form of music or other. Music is part of our everyday experience. And yet, many people are unable to participate in music beyond singing along to the radio or watching the X factor. What if our children could do more than this? Beyond getting skills for working life, what is education for, if not to expose our children to the wider world and to instruct them so they can be active participants in life?  This is especially valid for music, where some skill is needed to support participation.  Most people would agree that they enjoy music,  and those of us that have had the privilege of playing music with others are testament to the life enhancing experience that it is.  What is more, as James Rhodes pointed out in the first episode, we have a multimillion pound music industry in the UK, which will need future talent.  Schools do their best with the limited resources they have, but apart from a once weekly general music class (often taught by unqualified staff), any other musical training is usually an optional extra that comes with a price tag for parents. Because music is not adopted as an integral part of the culture of schools, children are left to 'go it alone' when it comes to the discipline required with practicing an instrument (especially if their parents are not musical themselves).  I think this is why so many children give up if they do start to learn an instrument.  

This lack of a musical culture in schools is further exacerbated by the (in my view, wrong) opinion that music is not a high priority subject at school or home.  The educationalist Ken Robinson highlighted this problem clearly, when he described the 'hierarchy of subjects'  - maths and literacy at the top of the hierarchy, with many hours and resources dedicated to these subjects, and music and art at the bottom.  Of course our children need to learn to read and write and add up, but this dilemma is so extreme, that school reports and SATs largely ignore subjects beyond literacy and numeracy in primary school (the sciences and humanities are paid lip service but very little more).  This is problematic for so many reasons.  Why do we need literacy and maths?  Surely partly to engage in wider learning!  Also, this approach carries the assumption that literacy and maths can't be learned outside of literacy and maths sessions!  I would argue that children could gain literacy and maths skills by engaging in music (and the arts in general - there is much to be said for drama and dance, but that is another blog!!).  Aside from the obvious lifelong pleasure to be gained from playing music with others, learning an instrument has so many benefits for academic achievement (there is evidence for impacts on language, maths, literacy etc).  Too often I hear parents saying that their children 'want to give up' an instrument after they have got over the initial excitement and are having to face the challenges of regular practice.  Funny how we never hear the narrative of wanting to 'give up' maths or reading!!!

The purpose of this blog is not to undermine or negate in any way the fabulous work that is already done by the unsung musical heroes in our schools music services, and the scores of talented and inspiring music teachers up and down the country.  Also it is important for me to point out that our local primary school has done a fab job of encouraging music with the limited resources it has.  But more is needed.  Like James, I believe all children should be encouraged to actually learn to play an instrument.  This blog is about supporting those who work towards supporting music, and positioning their role firmly as an essential component of learning in a musically active school culture.  Musical development is hugely beneficial for children and if nurtured in a positive culture, where music is an accepted and prioritised aspect of school life, I believe children would rise to the challenge of learning to play.  

Developing a musical culture in our communities.

Developing a culture means we all get involved.  Children are led by example, and if they see adults (teachers, parents and friends) engaging in and enjoying music, they are more likely to get on board.  This means that, as much as we are able, we should try to develop a musical culture at home too.  Perhaps we might enjoy it along the way!

Playing at a local festival 

There are many ways parents can encourage their children with music.  In 'Don't Stop the Music' James Rhodes has called an amnesty on all the unplayed instruments sitting in peoples' attics,  but before you give it up,  perhaps you might think about starting to play it again?  This would do wonders to encourage your children.  Join a musical group or form a band with your friends.  I learned to play the double bass after both my children had been born and were at school.  I'm no expert, but have fun playing with friends who have also either learned later in life or who have picked up an instrument once learned then forgotten.  Our children see us having fun and are encouraged to join in.

With friends round the bonfire on a camping holiday

The kids joining in with the music

Experiencing the thrill of the Royal Albert Hall

Another way to foster a musical culture at home is going to see live music.  The wider the range of genres, the better.  As a family we have recently been to a pop concert, our local festival, a classical concert at the Royal Albert Hall and a Royal Marines band concert.  Concerts can be expensive, but if we cast our eyes beyond the big stars the price tag comes down.  There are also often free classical events taking place regularly in churches, and in our home town there's always a gaggle of buskers on busy shopping days. This is a great way of democratising music, and helping our kids to see that you don't have to be a big star to play music (and there are more instruments than the guitar!).

A culture leaves a legacy

The British successes in the 2012 Olympics demonstrated that by building a culture for sport, people got inspired, and that encouraged participation and excellence.  Credit to James Rhodes for his part in developing a music culture for children.  We can all be part of this.  Not only will our children reap all the known benefits for learning music, but just think what legacy that might leave!

Can Big Data help research into language development?

Last Monday I attended an event at Cambridge University organised by the Cambridge Big Data Strategic Research Initiative (CBDRI) entitled "The vocabulary of Big Data".  I am cognisant of the fact that I am not a specialist in this area and, just as the title of the event suggested, I went along to dip my toe into this increasingly more useful approach to data analysis and gain at least a basic vocabulary.  Could embracing Big Data increase the possibilities for research into language development? Travelling up from the South Coast of England it was a fair distance, and I wasn't sure whether the event would be appropriate at all for me, an early career researcher with roots in clinical practice and one randomised controlled trial under my belt.  I wasn't entirely sure what Big Data even meant, perhaps it might be something to do with astrophysics, or analysis of Twitter use, or perhaps there might be other applications, such as language analysis, something I have used in my research.   This was a free event shared on Twitter and, not one to miss an opportunity, I went along.

There were 8 speakers in total, giving talks on Big Data from a range of perspectives. In this blog I am going to focus on just a few of those talks and the key aspects I learned from the event.

First we were introduced to the concept of Big Data, and why it was relevant today and in the future.  We live in a time where very large amounts of data are being produced, far more than ever before.  Social networking, genome sequencing, brain imaging, images, text and many more examples were given of the data generated.  It was also highlighted that this data generation is predicted to grow, and in 5 years time, the data we have access to now will appear as a drop in the ocean to data generated in the future.  By acquiring a vocabulary of Big Data we can begin the journey of learning how to tap into and benefit from the data that is produced.

The first talk by Professor Zoubin Ghahramani was an introduction to Machine Learning. In this talk we were introduced to the vocabulary of machine learning, which stems from the field of computer science and statistics.  Machine learning is a way to make sense of and manage large amounts of data.  An algorithm or model is created and built using the data which is input into the system.  That model can learn from new data and consequently is able to make predictions based on the data.  There are a range of different approaches used in machine learning, which include artificial neural networks, clustering and Bayesian networks.  These different approaches enable analysis and predictions in different ways.  We also learned about different applications for machine learning.  A well known example is that of the company Netflix, which used machine learning to more successfully predict consumer preferences.  Other applications of machine learning include object or photo recognition, speech recognition and natural language processing.  The benefit of machine learning is that, as it is able to learn from data it does not rely on a fixed predesigned algorithm to start with.

A real case example of the application of Big Data was presented by Dr Richard Gibbens who described how Big Data was used for road traffic modelling, demonstrating how the large amount of information gained from motorway sensors was used to predict and manage traffic flow on Britain's motorways.  He highlighted that this data was already collected for another purpose and was therefore available but through analysing the data his department were able to provide the Highways Agency with really valuable information about traffic flow, which is now contributing to road safety.  Whilst traffic data isn't something we're likely to be mining in the field of language and communication, the case study highlighted that a Big Data approach can exploit data that has already been generated for another purpose to answer questions.

A problem with handling Big Data is just that; it is big!  The issue of handling large amounts of data were addressed by Dr Anders Hansen, Dr Eiko Yonkei and Dr Jan Lellmann.  Through their talks we were introduced to the storage and processing issues encountered when dealing with Big Data.  We were introduced to the concepts of compressing data. We were shown two images of earth, one with all the data and one with the data compressed.  To the naked eye, it was impossible to see the difference between the two, and this highlighted the fact that most of the information held in a data sample may be gleaned from a small percentage of that data.  We were shown how this approach can be used in brain imaging to provide a high level of focus on an area of interest, such as a lesion, without significantly increasing the amount of data processing.  The ways in which large amounts of data are stored were also addressed. In part, Big Data can now be stored effectively thanks to the ability to use multiple servers and cloud technology.

The event ended with a case history of natural language processing presented by Dr Paula Buttery.  She showed how natural language processing could be used to gain information from large sources of text using algorithms, and how the syntax of language could be used to make predictions.

This event really did give me a basic vocabulary of Big Data and an awareness of how it might be useful in language development research.  Undoubtably, Big Data approaches will already be employed in the field of genetic research and the neuroscience of language development.  I believe Big Data may be employed in the same way concerning environmental influences on language development.  Having spent my last research project transcribing hours upon hours of parental talk to children I am very interested in how we may embrace both new technologies of data capture and the discipline of Big Data analysis to make progress in this academic field.