PTJ Author Interview: Understanding Barriers to Clinical Practice Guideline Use

Welcome to this APJ Podcast. Welcome to the PTJ Podcast, where you can get the story behind the research with insights in the clinical application, study design, and future projects planned. Now here's Editor-in-Chief Stephen George. Hello and welcome once again to the PTJ Podcast. Today we are highlighting the article, Understanding Barriers to the Use of a Low Back Pain Clinical Practice Guideline in Physical Therapist Practice, a mixed methods approach. Joining us for the discussion are three of the authors, Matthew Schumacher, Kyle Katon, and Laura Syveter. Matthew is affiliated with the University of Mary in Bismarck, North Dakota. Kyle is affiliated with Bradley University in Peoria, Illinois, and Laura is affiliated with the University of St. Augustine for Health Sciences in St. Augustine, Florida. I welcome each of you, and I'm looking forward to the discussion today. Awesome. Welcome. Thank you. Thank you so much. Thank you for submitting this interesting paper to PTJ, and before we begin, I wanted to disclose for our listeners that may not be aware. I was involved with the Clinical Practice Guidelines you investigated in this article, and I'm mentioning this purely for informational purposes, so our listeners have the proper context in listening to the discussion. I don't think I need to say more than that, just that I'm intimately familiar with the guidelines that you focused on. Let's start off. I think one of the issues at hand is fairly well known, and we all know, especially for back pain, there's multiple practice guidelines that have been published, and those guidelines do not seem to make a noticeable or a sizable dent in shaping clinical practice. This paper, I think, adds some insight for reasons why that may be. I want to start off with a question about your methods. We don't spend a ton of time talking about methods, but I think for this paper, it's worth spending a little bit of time. You do mention this some, but I like to hear it from the author team directly. Why did you go with a mixed methods approach? Yeah. I can jump in. I think when we first initiated the study, I think we wanted to get a larger sample size with the survey that was going to help us in determining some practice trends around the country and attempting to get all across the United States and seeing what's happening out there, but the qualitative component of that mixed methods study allowed us to really dive into those nuances and limb experiences of the participants that I don't think we would have gotten just through the survey alone, and I think we can all attest to that. We found, "A, there was quite a bit of overlap, so that was good to see between the survey and the interviews, but the interviews just allowed us to dive into that deeper and get a better understanding to some of these nuances, and I actually found it quite fun to sit down and interview some of these individuals, treating well back pain, and we heard quite a few different stories and biases and things like that, so it was fun, and I think this process, the mixed methods study allowed us to be able to do that." Yeah. I'll cut a piggyback on that. I think the understanding the wide behind somebody's choice to use or not to use or deviate from the clinical practice guidelines was kind of an important concept to help us better understand those barriers like Matt was saying, and just like Matt said, this was all three of our first times doing any kind of qualitative research, and so with this mixed methods, it was really interesting, and I've really found myself enjoying talking to other clinicians about why, like tell me more about this, so it was very interesting to me for sure to go through this process. So you think, I'm going to put words in your mouth, you can deny or confirm, but just to reflect a little bit back. So you think for this particular research question, where a lot of the research was more kind of a binary are you using it or not, and estimating rates of that, that there is some advantage, like you said, to doing a little more behind the why. So you think this type of approach maybe is something that could be used to model for other physical therapists to that maybe have similar questions about practice guidelines use in other clinical areas, or maybe even some other types of research questions, we're knowing a bit more behind the survey response at additional insight. Yeah, I can jump in on that a little bit. So I think having that qualitative piece gave us a little deeper insight to be able to to be into address these barriers. So with the survey, they're just telling us that these barriers are existing, but it's not diving into the why behind them. So being able to have that deeper understanding of what each of those barriers are, you can then begin to dive into not only what the barriers are, but potentially how to address those barriers to change and improve overall use of CPGs. Yeah, and I can see these being the mix methods approach being used a little more regularly with some of these deeper questions that might have these more nuanced answers to them. You know, it's not just do you use them, do you not? But the understand to be kind of okay, like why do you choose to use them or why do you not choose or why is this a barrier? Was it a barrier because for you, you just didn't understand them well or was it a barrier because you had no idea about these in the first place or no, my views really focus on this and this is what I've always been taught and this is what I want to go after. So I think it just helps us better understand that concept and I could certainly see these being used mix methods more with more of this type of research and I feel like I want to try and go down that route a little bit more too because it does help me better understand those concepts. Yeah, and certainly feels like and we may get into this a little bit later, you know, feels like the data a little more actionable when you know the Y versus just the, you know, the rates, like I said before and for those of you, you know, old enough to remember the YSQI campaign from a certain beverage, I think you have all outlined very good reasons to ask why, you know, in talking about use of practice guidelines. Just moving along a little bit, you know, there is, there always seems to be and I think your study identified it nicely, the tension between what the guideline recommendation is and, you know, does it or does it not match the patient in front of you and that was evident in that lack of individualized care barrier. You know, can you provide or comment a little bit on how, you know, maybe the qualitative part provided more insight into why this remains such a highly relevant issue and I think I'm also interested in, you know, future thinking thoughts are there, does this study give you some insight on how guidelines might want to handle this a little bit better in the future. So that's a two-parter, if you're keeping track, you know, at home. Yeah, I think, you know, we identified, as you mentioned, the interviews and the survey both identified, this was the top barrier to using this low back pain clinical practice guideline. Now we've talked a lot about, you know, the different nuances of this barrier and what that was looking like and the couple things that we highlighted were a, just a lot of people view them, at least in the conversations we had through the interviews, getting the why. They view this as a cookie cutter approach, a black and white approach and we know that that's not the intention of the guidelines and so that really was evident, I think, in our interviews and seeing how many people just felt that this human being sitting in front of me was so complex and the guidelines were black and white and the reality was that that's obviously not really the case at all and maybe I'll let Kyle and Laura jump in here as well if you have any other thoughts on that. Yeah, I mean, what we were founding is that that lack of, you know, understanding on how to use and was impacting their ability to use them at all, so figuring if they couldn't use a small part of it, then they couldn't use them at all. So it's, you know, giving us an opportunity to dive into why is that a commonality we're seeing people believing that they have a lack of individualized care in those guidelines. So, you know, it gives us things to look at and, you know, how can we address that barrier in the future. So that's why we enjoyed doing these interviews, but it was interesting to see how many people believed that it was either all or nothing approach to using the guidelines. I think that comes back to one of our other findings, too, of the, just the understanding and awareness of the clinical practice guidelines, they weren't, there were individuals who just weren't aware of what they were, how to use them, didn't know that they're typically open access, especially through the ones through PTAJ and things or JSPT. And so I think they, some of these barriers kind of came together a little bit with that. So lack of awareness and understanding can lead to this lack of, or this feeling that they're not, or can't be used for individualized care. And, you know, that, that black and white cookie cutter, like I think people sometimes were wanting it to be more algorithmic, like if this than that, whereas really it's more kind of summarizing the research, what's out there, what do we know now that could be valuable for these, these type of conditions, instead of saying, Oh, if you have this, then we need to treat with this specific intervention. Yeah, and I think even to tie into that, a lot of these individuals reported the sense of losing the autonomy of their clinical decision making with following the clinical practice guidelines, and again, not that one would take precedence over the other, but that they would coincide together and help inform your clinical decision making, you know, moving forward. And so to your second part of the question, I've thought a lot about that, you know, what's next or how can we, you know, help, you know, do a better job of addressing the important issue. I don't know that I have really answered to that, but a couple of thoughts I've, you know, thought of as a, we have to identify the barriers, which I think we were able to do within this study, as well as, I don't know, providing a clear message that this is not to replace your clinical decision making. This is a guideline. And again, based off of the conversations we had in interviews, I also think maybe having some, you know, couple case examples or case studies of, even to like this patient with full back pain come in and based on these things, we went down this route, and we still followed the clinical practice guideline. But maybe case number two looks a little bit different, right? And that's consistent with clinical practice. So, you know, I think providing a clear message about the flexibility and clinical judgment and how these need to coincide together could potentially help bridge that gap. But I, I think that's a, that's a powerful question. And the first thing we identified again is just the barriers itself. And so, I think it's a good start to kind of how we navigate this moving forward. Yeah, and this is the part where I try not to sound defensive, but, you know, we thought about this a lot. And, you know, there's some constraints with the language that you can use. I agree, you know, that providing some information that these aren't prescriptive. I think we try to do that, but maybe just being more upfront about that. But then when you look at the framing of the language, you know, like the code should, you know, that type of thing, I know there's been a move in guidelines to make it sound more, you know, that it is an integrated end of the decision making. But even, I think, more work can be done there. I think probably the asymmetry now and how we assess and grade evidence is way ahead of the, you know, actually seeing how that translates to, you know, effectively being communicated to providers and to patients, you know, I think that when you look at some of these recommendations, I know that, you know, traditionally these aren't geared towards patient audiences, but I, in the future, you, you know, I think you'll see more and more involvement from that partner. And I think that will really press us on the language that we use. The other thought we had on that team and that paper, what the paper you were referring to was published in JOSPT, not PTJ, but it was in JOSPT, the, you know, we talk a lot about hopefully the evidence will be able to support more of, you know, for whom are these treatments a good match. And that's, that's just not how design, a lot of drain in my trials aren't designed that way. Yet, and it's not, we looked for them, trust me in that group. We wanted to find some of those and they're just, they're not there yet. So for, for us, it was a reminder, you know, that hopefully people are thinking about how to design the trials that way, because knowing just a little bit about who may benefit from one treatment versus another, I think is as helpful and maybe more helpful than just knowing what the overall, you know, evidence for a specific treatment is. So, you know, we've had, I asked the question, obviously, I've been thinking about a little bit too, so I think I agree this is an area that is ripe, you know, for future thoughts and future work. And, and I think the, the qualitative work really helps people understand the importance of this. Yeah. I'm sorry. Go ahead, Kyle. No, I was just going to say, I think too, like when you think about each individual barrier, like the, the understanding and awareness barrier, like that's one area you can go after the, you know, the idea of this, this indoctrination, you know, or where people were, you know, what they've learned in school or what they've learned in continuing education classes. I mean, you know, that's another barrier to kind of look at, you know, like how are these being utilized in, you know, DPD schools? How are these used in, to education, or is there any, you know, any way to integrate that better or what is or isn't working for that? So I feel like each of these barriers are just another opportunity to kind of see, okay, how can we maybe affect this small component of it to, to get a, a better overall kind of reach for, for those individuals that, that seem to have barriers to using these. I mean, I agree. I mean, one of the, one of the bigger things that we found is that people just simply didn't know that, where to access them, you know, so they can't access them. There's no chance of them using them at all. So where does that come from? Does that come from, Jim's saying in their DPD education, Jim's saying in the city there, does it come from continuing education? Does it come from, you know, more advertising, you know, in some, you know, respect to just awareness of where they can find them? So there's lots of different components that we can address to increase the utilization of them. But like our Kyle said, it's kind of where, you know, where do you start with, it's going to have the biggest impact, and it's not, you know, necessarily, you know, even diving into the, the guidelines themselves, but just starting with where can they find them because if they don't know how to find them, there's no chance to use them. Definitely. And, you know, I think that brings up a good point about the previous experience indoctrination barrier, and, you know, I really saw the interplay there between the lack of clinical skills and confidence. And I think we've hit on some of that, but just to talk a little bit more around that, it seems like, you know, we would, you would think, surmise, maybe programs that, you know, embed going to the practice guidelines, maybe would create clinicians who are more comfortable with doing that. But, you know, I was really, I tried not to read too much into it, but it seemed like those two had some type of, I don't know if it's a symbiotic relationship, but they definitely were playing off each other, whereas, you know, if, if traditional continued education isn't using these to reinforce skills, and the person isn't exposed to it in their training, there's probably not a really good chance that they're going to understand the value of practice guidelines. And I, I think one's probably more malleable than the other. So, you know, I wonder, do you think that's a fair way to look at this or, you know, should I not try to push those two together? I don't know what you all thought about these barriers. Are we allowed to, you know, lump them together and see if there's ways that they relate to each other, or is it better to think of these themes with the way you did the qualitative analysis as kind of being separate and equal? I think it's a fair assessment. It's something that we've talked about, and I think there's commonalities in all of the barriers themselves. But definitely to your point, this was, I think, part of, at least Kyle, Lauren, I definitely a major interest moving forward, is this previous indoctrination that seemed to dictate practice trends over the clinical practice guidelines. We could recount several floats and phrases, pretty outrageous quotes and phrases from a lot of these individuals just saying how they weren't taught in the DPT school because they, their professor didn't believe in joint manipulation or mobilization. Should be, you know, PT scope of practice. I mean, just some quotes that were so outrageous. And so, yeah, that's, you're malleable as a PT student and that's what you're coming out of PT school with. I mean, there's no way you're going to be doing this, even though there's great evidence to support it, unless you get in with a different mentor or different continued education course. Like I said, I think it's a fair assessment to kind of tie those together and it definitely is an area that really sparked our interest for future research in this realm moving forward. Yeah, and I think those types of statements show the power of kind of that local influence, you know, that it's always, you know, going to be, have, have a, you know, higher weight on those experiences and opinions of students and you can have, you know, I think a fairly a decent clinical practice guideline, but all it takes is, yeah, someone early on saying, like you said, I don't believe in that or that's not something we do and it's very hard to overturn that. What about, you know, the patient expectations and perceptions barrier? I think this is always an interesting one. You know, what do you think, how should this be weighted and let's say we have a clinician who is in a good faith, you know, trying to use the guidelines and it is, you know, oppositional to the patient preference for treatment. But can you think of some ways to help folks handle that and, you know, are there ways that, you know, you could use this to build therapeutic alliance instead of it always feeling, you know, like it's oppositional because, you know, I think there are times that is truly the case, but I also think, and I'll be the one to say this, that sometimes providers may use that as a cop out to stick with something, you know, that maybe they feel more comfortable with. So that's my interpretation of that, that doesn't have to be yours, but I'm wondering, you know, are there ways to use the guidelines to build therapeutic alliance other than just, you know, agreeing with the patient on their preference every time? Does that make sense? Yeah, I think this is, I mean, a barrier that we solve, you know, more with newer clinicians compared to more experienced clinicians, but, you know, through patient education, it's a great opportunity for patient education. You know, we're, you know, as the provider, you have that expertise and you need to be able to relay that also to your patient to gain that buy-in with them as well, because, you know, if your patient's dictating your level of carrying your treatment, they're not the ones who, you know, have that education behind them to make them better. So they're still relying on your expertise there. So it's a great opportunity to get the patient involved, educate them about, you know, what you're doing, educating them about the resources that are available and the evidence behind the treatment interventions that, you know, you want to implement. So getting that buy-in from the patient can also improve that therapeutic alliance between your patient and the provider and, you know, ultimately help you feel more comfortable providing that care. But those newer clinicians have a harder time with, you know, that fear of that patient response, you know, so it is harder for that newer clinician to provide that, and that's where maybe some education or some mentorship could come into play for those newer clinicians to be able to gain that confidence in not only themselves performing those skills, but also working with their patients and gaining the confidence in buying from their patients on that. And as they see, you know, they're gaining more positive, you know, patient outcomes that builds that confidence to be able to, you know, back the use of them to their patients as well. Yeah, I think that the term shared decision making always comes up to me and it's that education piece I think is the largest component, you know, explaining to the patient, okay, this is what we have. Some options we have. This is, you know, what we find in these kinds of practices, we find in the research and kind of trying to say, is this an approach that you'd be comfortable with? But I do think that that, like Laura was saying, the confidence of the clinician has to be there. So even more, you know, more mentoring or more of those conversations with the newer clinicians and more pieces of that being taught in DPT school to have those tougher conversations, maybe that's the, maybe those younger clinicians don't necessarily have. But I just think that education pieces is the biggest and really trying to talk to the patients themselves about what do we know about the research that's going to help you. And this is a component that we can, we can branch from. But I do also understand your point, Steve, it's talking about like the kind of the compound or the, oh, well, you know, they don't want that. Well, did they not want that or for you as the clinician or you not confident or comfortable with those techniques that kind of feeds back into some of those other barriers of confidence with skills or what you've been taught from past experiences too. And that can definitely feed into how you interact with the patient. I really agree. I think Kyle, Lauren and I, we still even treat in the clinic a little bit. And this just came up this week and the clinic, it's, this patient comes in with chronic little back pain, right? And you ask, as a good provider, right, you ask, what, what have you done in the past? And, you know, it's the hot packs and ultrasound and EastM and that's it, right? And obviously need to build that connection that they're particularized that we talked about. But, and it's hard to do that if you don't do that, right? It's hard to educate them and get them on board if you don't do that. So I recognize both sides there, but I feel like I'd be remiss to say that I would be doing a disservice to this patient if I didn't at least explain or try to implement some sort of active strategies, strength training, stabilization training that she hasn't been doing for the past 10 years. And so it definitely is something, you know, a skill that I think needs to be reinforced as they mentioned. And I also think, as we found in our quantity of analysis, novice clinicians are having a harder time adhering to that. So maybe mentoring in that regards and talking about that would be good moving forward. And, you know, and looping back to some of the other things we talked about. The novice clinicians are probably ones that are least comfortable with the guidelines to begin with. So it's not, you know, they're maybe not as comfortable with it as someone who, this is their third or fourth practice guidelines that have come down the pipe. And, you know, it's not, you know, it's not written in stone. And, you know, there's some things that are, you know, like you said, that aren't prescriptive, whereas, you know, maybe the novice clinicians fear, you know, that there's just, maybe they're overinterpreting it and that makes it, you know, harder to communicate to the person in front of them. And, you know, I, it's been a while since I've practiced clinically, but I can remember, you know, some people are pretty adamant about those hot packs in East M and, and you're going to give me, you know, four of those and then I won't bother you for a little while again. So, you know, I, I do, I do remember those, but, you know, it's that foot in the door sometimes well. You want, you know, there may be something that can, if you keep up with, it may decrease your number of episodes, you know, it's not going to cure you, but maybe you'll have fewer episodes in the next year if you keep up with that, you know, having those conversations. So, while we're getting near the end where, you know, we like to give the guests kind of, you know, a chance to have the last word, whether it's something you're working on the future or any message that you want to reinforce or that we didn't get to. So, with three of you, I want to make sure we move through that pretty quickly. So, you can, you can determine the order, but, you know, kind of as we move into wrapping up, you know, any thoughts you'd like to share as kind of the, as we work here towards the end. Yeah, I'll jump in here. I think one of the things I'd like to say is that, you know, I think these, these clinical practice guidelines are great for the profession. It's really giving us a sense of what's out there and it's something we need to continue to, you know, see pushed into DPT schools into continuing education. One nice thing that we did find with the article is the younger clinicians were more likely to be, or at least state that they were using the clinical practice guidelines. So they're becoming, you know, more aware and using it more regularly or for their perception, which is nice to see. And hopefully that trend will continue because I know me and Matt and Laura have talked about this when we came out of school, like clinical practice guidelines weren't necessarily a big thing at all. And so, you know, I'd never seen one. And so now as it's becoming more and more prominent, more and more areas are, are having these CPGs, I think it's, it's more evident that we, this needs to probably be addressed in DPT school and then in continuing education as well. Yeah. I think the biggest thing, as I mentioned earlier is Kyle Lauren, I are really interested in this indoctrination. We all teach in DPT educational programs in the United States. And, you know, I think CPGs are a fantastic way to teach DPT students best treatment interventions. It's kind of a cheat sheet for you and some of your clinical base courses for these conditions. And so we'd like to explore that further and see how are they being implemented into DPT entry level education? Because I think as we learn, right, this indoctrination, if we can get to them right away in DPT school, and at least introduce it to them, because we, we also identified up to 36% of individuals aren't familiar or are not using this. And so we have some work to do, but I think it's encouraging, as Kyle said, novice clinicians aren't using or reporting using it more. And so I just know that we've discussed that's definitely an area of research continuing that route of now, what about continue education, what about entry level education? How can we introduce this, do they appear in our classroom, all of that and moving forward. So excited to do that. >> Yeah, and I'll echo Matt and Kyle, we're excited for what we were able to find through doing this research and where we can address the differences that we found in using the CPGs. So we've identified a few of those areas, like I said, that previous experience in indoctrination is a highlight for us, and something that we feel like we could dive into. So we're kind of fired up on where else this might take us, so watch out. >> Yeah, we've been warned, we've been forewarned, I like that. And I'll just add, I think the other thing that's cool, though, you know, I'm a low back pain, that's my area of interest. I think these lessons you're learning should be highly generalizable, right? These things we're talking about, some of it's specific, but I think some of it will also generalize to other practice areas. So it'll be interesting to see the convergence, and I think there's potentially a lot of lessons that could be applied to educational strategies, and people don't like probably the word indoctrination, but I think it's an appropriate use of it because it does stick and it does last that early exposure to the profession, and we probably need to keep thinking about, you know, what are the best ways to expose people. So thank you, thank you very much, thanks for submitting the article. Thanks for the work, and thanks for taking the time to talk a little bit more about it on the podcast. >> Yes, thank you. Appreciate it. >> Thank you for having us. >> Yeah, thank you so much.