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Editor's Notes |
alanjette{at}apta.org
As a physical therapist student, I discovered that the "contemporary physical therapy" I had learned in school wasn't being practiced in many of the clinics in which I was doing my affiliations. What I had been taught wasn't what was being done in the "real world" of clinical practice! I remember thinking (naively), "What is wrong with these people? Why don't they get it?"
That was my first introduction to the challenge of disseminating innovations across clinical practice. Although I have never forgotten my initial shock, I have since come to understand that the slow pace in adopting innovations is a widespread problem in health care, not just in physical therapy. As stated so aptly in the Institute of Medicine's report Crossing the Quality Chasm, "Between the health care we have and the care we could have lies not just a gap, but a chasm."1 Or, as Berwick2 noted, "In health care, invention is hard, but dissemination is even harder."
Why is there such a chasm between new knowledge and health care practice? Why don't clinicians readily incorporate the findings of clinical research quickly into their daily clinical practice? Is there a knowledge gap, or is there something more fundamental and complex involved? What can professions do to speed up the dissemination of innovations into clinical practice?
The universality of this challenge was brought home to me a few years ago when, in a JAMA editorial, Institute for Healthcare Improvement founder Donald Berwick, MD, MPP, retold the story of the British navy's long fight against scurvy.2 He recounted the work of Captain James Lancaster, who, in 1601, as commander of a 4-vessel fleet on a voyage from England to India, conducted a simple experiment. He gave the crew on one of his ships 3 teaspoons of lemon juice per day during the voyage, and, at the halfway point, he discovered that 40% of the crew members of the other 3 ships had died of scurvy, while none of the crew had died of scurvy on the ship where there was a ration of lemon juice. Despite Lancaster's compelling evidence, no one seemed to notice (possibly due to the nonrandom allocation of the treatment arms of his experiment, his small sample size, or serious selection bias...). Dietary practices in the British navy did not change! Astonishingly, it wasn't until 1795, after several replications of Lancaster's seminal experiment, that the British navy adopted the innovation and ordered citrus fruit as part of the diet on all of its ships; scurvy disappeared almost overnight.
As the fight against scurvy shows us, disseminating innovations is a challenge known to many human enterprises. The process and stages of dissemination have been well characterized in the social sciences and are called the "diffusion of innovation." In his work on diffusing innovations in contemporary culture, social scientist Everett Rogers3 highlights 3 primary sources of influence that relate to the speed of adopting an innovation: (1) how the innovation is perceived, (2) characteristics of the people who do or do not adopt the innovation, and (3) contextual factors such as leadership, management, incentives, and communication. According to Rogers, all 3 sources of influence must be addressed to accelerate the adoption of innovations.
The challenge of this diffusion—and the potential to speed it up—are nicely illustrated by the study by Brown et al reported in this issue of Physical Therapy. Their focus was on the use of evidence-based falls prevention strategies by physical therapists working in north-central Connecticut. Unlike Captain Lancaster of the British navy, these investigators were able to achieve a striking increase in the use of prevention strategies, with two thirds of physical therapy providers reporting increased use in response to the introduction of a complex, multifaceted, intervention program. This program involved a thoughtful array of strategies, including outreach visits to therapists, support by clinical administrators and supervisors, training manuals, risk-factor handouts for therapists, educational handouts for patients, a Web site resource, working groups of local therapy providers, encouragement from "opinion leaders" and "early adopters" of the program, newsletters, and mass media vehicles.
From one perspective, the work by Brown et al illustrates that the process and pace of innovation dissemination in the area of falls prevention can be affected by a program that follows the principles of diffusion of innovation. For me, this study has potentially broad implications for the field of physical therapy as we attempt to move our clinical culture toward one that supports—if not demands—evidence-based practice.
An important implication of the research by Brown and colleagues is that the scientists and academics among us must take the science of diffusing innovations just as seriously as we take the science of producing innovations. If the physical therapy profession is to create a future that differs from our past, we need to become students of the science of diffusion of innovation to better understand how innovation spreads, to draw on the social sciences for guidance on how to move the process in the direction needed for contemporary clinical practice, and to develop intervention efforts that can be institutionalized throughout our profession. Real change will require us to advance beyond presenting our papers at scientific meetings, beyond participating in continuing education seminars, beyond publishing our work in scientific journals, and even beyond teaching our students to aggressively apply the principles of dissemination and knowledge utilization.4 Journals can contribute to the effort, as illustrated by JAMA's recent introduction of "Author in the Room," a mechanism that allows readers to explore specific peer-reviewed articles directly with the authors of those articles.5 Stay tuned as Physical Therapy moves toward the capability to host similar interactive features online.
Advancement of practice requires an understanding of innovation and how it spreads. Let's not make the mistake I made as a student by assuming that the problem is simply a lack of knowledge on the part of clinicians.
References
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