Dissemination Tools and Resources: Assisting Colleagues in the Implementation and Promotion of EBD Principles

Presentation Level Appropriate to Audience 

In presenting the concepts of evidence-based methodology, one should attempt to match the message to the audience. On more than one occasion lecturing to students, residents, and the practicing community I have jumped into a discussion of experimental design, only to realize that my message was wide of the mark and I was looking out at blank faces. The message must be appropriate to the interests and background of the audience. For those new to EBD, the hope is that an appropriate and well-delivered message will stimulate interest and learning resulting in a more sophisticated understanding in the future.

Straus et al13 have developed a conceptual framework that I have found useful in a simplified form. Evidence-based methods include the following: (1) asking a clinically relevant question, (2) acquiring the evidence, (3) appraising and analyzing the evidence, (4) applying the evidence in the clinical setting, and (5) assessing the outcome.14 Those “doing” evidence-based methods must become proficient in all 5 steps. This requires some sophistication in understanding search methods, experimental design, analysis, and grading evidence. Those “using” the resulting evidence require background in the methodology, but not the skills required for steps 2 and 3. They must learn to access and use previously analyzed and digested evidence provided in systematic reviews and practice guidelines such as those provided by the Cochrane Collaboration and accessed with the ADA's search engine.2, 4 The concept of EBD “doers” and “users” can be helpful in considering an audience and tailoring the message to the appropriate level. It is also helpful in planning sessions for an evidence-based dentistry study club, providing a framework for increasingly sophisticated activities as the group's understanding matures.15, 16

Time 

One very real problem for anyone attempting to use EBD in their practice is “when do I find the time to do this?” EBD processes take time, even more during the learning phase, and where will it fit in our busy practices and lives? This has been an issue for training medical residents in evidence-based medicine and it is an issue in training dental students/residents.16, 17 I would suggest setting graduated goals for practicing EBD methods. It is reasonable to start out as a “user” and begin by making a commitment to look up systematic reviews and/or guidelines regarding one clinical problem a day. Over time this could evolve into developing the skills of a “doer.” It has been my experience that as I have become more efficient, EBD has become a necessary and integral part of my practice.

Active Participation 

One avenue for advocacy and education is through the study club culture so prevalent within the dental profession. As this has been more thoroughly discussed in other papers in this issue, commentary here is restricted to the value of active member participation, as opposed to passive listening. The medical literature has clearly identified the need for active participation by students in the practice of evidence-based care.18 Although knowledge is increased with didactic courses, skills, behaviors, and attitudes are not. This has also been our experience teaching dental students and residents. The students/residents must be involved in developing the clinical questions, acquiring the evidence, and analyzing the evidence, if practice behaviors are to be changed.19

Recently I was asked to give a participation course by a local dental study club on the topic of occlusion. As I was given latitude regarding content, I structured a session around testing reliability of occlusal contact measurement in the intercuspal position. This was done similar to the calibration of examiners necessary for any clinical study. The participants were provided background regarding clinical methods in the literature and then sent to the clinic with varied materials to test. The group was divided into subgroups of 6. Each group was instructed to develop a detailed, operationalized method, including materials, patient instructions, and interpretation of findings. Subsequently one member of each group served as a subject and the other members of the group measured and recorded occlusal contacts blind to each other's findings. The poor interexaminer reliability observed was surprising to the participants and led to a greater appreciation for issues in clinical measurement and research.

Library Support 

The digital age has resulted in a significant change in the function and structure of libraries. There is considerable debate among library professionals and academic leaders as to whether the traditional library physical space should be changed or whether a physical space is even needed. The role of librarians and their training is also evolving quickly in a world where almost everyone has access to the Internet.

In this changing world, practitioners of evidence-based medicine continue to recognize the importance of good library support, particularly for librarians versed in electronic retrieval of information.20 These professionals essentially provide the same support they always have, in a new and even more comprehensive manner within the digital age. The librarian is no less valued in the world of EBD, as every EBD methods course in which I have participated has included a librarian on the faculty.10, 11 I have typically had support from our library in teaching predoctoral, graduate, and postgraduate courses on EBD.

I would advise getting connected with a library and a librarian as you become involved in teaching and advocating EBD. Your local dental school, academic health center, or alma mater's library would be excellent. Many schools provide some library services for their alumni. Your American Dental Association's library also provides services available to its membership, a growing portion of which can be accessed on-line.2

EBD and The “Doctor-Patient Relationship” 

One of the most frequent concerns I have heard is that EBD will not allow treatment of patients as individuals. There is a sense that this is a “cookbook” approach to care. Careful consideration of the definition of EBD by the American Dental Association,2 as well as the original definition of evidence-based medicine provided by Sackett et al,1 should lay this to rest. The consideration of the individual patient and the role of the clinician's judgment in the process is clearly articulated. And yet, this continues to be of concern even among proponents of evidence-based care. Ms Susan Lockwood has written a very effective paper on this topic from her perspective as breast cancer survivor and patient advocate.21 She makes the case for active listening to our patients' stories. Another source, although dated, I still find helpful for my students/residents is the book by Dr Edward E. Rosenbaum, which was made into the motion picture, The Doctor, starring William Hurt.22 Reading and carefully considering works such as these will help us provide more compassionate and effective care for our patients in all aspects of our practices. Care based on EBD can be as compassionate as any other care. In fact, when the patient is brought into the decision-making process, it is more patient-centered.

EBD and Insurance Payers 

One concern often expressed is that EBD will be used by insurance payers to deny coverage for provided care. It was this concern that led the Marketplace Committee of the Minnesota Dental Association to develop a resolution subsequently passed by the House of Delegates in 2006. This resolution called for appointment of a Task Force on EBD “to develop a process to increase dentists understanding, utilization, and development of ‘evidence-based dentistry,’ in consultation with the American Dental Association and the University of Minnesota School of Dentistry.” As the impetus had come from the Marketplace Committee (Resolution from the Dental Marketplace Committee: topic: evidence-based care. Minnesota Dental Association House of Delegates 2006 Manual, Minneapolis, MN, 2006;203-204.), the Task Force developed a symposium about EBD from the perspective of third party payers. The symposium, cosponsored by the Minnesota Dental Association and the School of Dentistry, was held October 12, 2007 with over 120 in attendance. The keynote address was provided by former US Senator David Durenberger, a health care policy maker currently directing the National Institute of Health Policy in Minneapolis. He discussed the issues facing health care and his appreciation for dentistry's role. His closing message was “either be at the table or be on the menu.” The body of the program included presentations by executives of 3 local dental insurance companies. Topics included the need for the ADA to continue development of diagnostic codes, evidence for increased benefits with some systemic health conditions, and disease management of caries and implications for payment. The opportunity for face-to-face meeting of practitioners and insurance executives was lively and informative. The presenters' PowerPoints are available as PDF documents on the Web site of the School of Dentistry, University of Minnesota, under School News Archives, “Evidence-based Dentistry Symposium Generates Interest.”23

EBD and its impact on care decisions and coverage will always involve some necessary tension between care providers and payers. This was articulated eloquently by Dr Max Anderson at the 2nd International Conference on Evidence-based Dentistry.24 This is not a reason for failing to engage EBD. The tension of this check and balance will be most productive with active dialog. I encourage you to engage and participate.

The Need for Clinically Relevant Evidence 

Although growing exponentially, it is obvious that the evidence base in dentistry is not of optimal quality or quantity.25 One of the significant problems is that the available evidence often is not clinically relevant. There is need for investigation of problems of concern to the clinical practitioner.26 The ad hoc Task Force on EBD of the Minnesota Dental Association has been exploring interest in the possibility of the Association promoting the participation of its members in practice-based research networks (PBRNs). The National Institute of Dental and Craniofacial Research has invested $25 million in 3 PBRNs.27 These PBRNs provide a structure for clinically relevant research performed in general dental practices. In medicine, these PBRNs have developed into “collaborative learning communities” where questions posed by practitioners are investigated in daily clinical practice, providing evidence credible to the community practitioner.28 The role of PBRNs as a possible source of clinically relevant evidence is deserving of discussion and possible action in the future.