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

Explore the evidence-based treatments for Childhood Apraxia of Speech and understand how behavioral economics can help speech pathologists implement these practices effectively. This lecture also discusses the impact of cognitive biases on clinical decision-making.

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

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  1. Elizabeth Usher Memorial Award LectureHow 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. Speech Pathology 2030: A positive scenario All speech pathologists confidently and consistently use and contribute to the rapidly growing evidence base.

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 These services continued with outdated approaches and ultimately only attracted clients not well equipped to scrutinise what was delivered.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

  6. What is the evidence in treatment of childhood apraxia of speech?

  7. 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

  8. 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, 486-504.

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

  10. Rapid Syllable Transition TreatmentReST http://sydney.edu.au/health-sciences/rest/

  11. Outline of ReST research program

  12. 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

  13. Guilt – or true confessions of a researcher practitioner

  14. 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

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

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

  17. 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?

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

  19. 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…

  20. 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

  21. Two systems of decision making 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 http://www.behaviouralinsights.co.uk/publications/mindspace/ Based on

  22. 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

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

  24. EBP through a behavioural economics lens

  25. 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 & Pettigrew 2009, Vallino-Napoli & Reilly 2004, Skeat & Roddam2010

  26. 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.

  27. 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

  28. 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.

  29. 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) 120-128. 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

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

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

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

  33. 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

  34. 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)

  35. 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

  36. Shared decision making aids – an example

  37. Our ReST Shared Decision making tools

  38. Clinician decision making tools ReST clinician toolfor step up- step down in therapy

  39. Other people’s opinion & behaviour mattersHeuristics #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

  40. 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

  41. 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”

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

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

  44. 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?

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

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