AUTOPP

Association of University TMD and Orofacial Pain Programs

Newsletters Spring, 2003

Education Program for AUTOPP:

Presentation by John Rugh PhD.

In his talk, Dr. Rugh described the process by which new scientific knowledge is translated to the public. He noted the problems with the present system, and he suggested some alternative strategies for moving new information to benefit public oral health more quickly. He argued that science transfer is similar to U.S. foreign policy in that it may be more of a political/economic issue than an issue of science. Improvements in public oral health through research ultimately require dealing with the economic realities of private practice, the politics of public health programs, and sometimes, legislative issues. He urged the scientific community to become informed and be involved in these issues.

In several areas of dentistry, this model has worked effectively. For example, implant dentistry involves collaboration among academic biological and material scientists and industry with reasonably rapid dissemination of results to practitioners and to the general public. In contrast, dental sealants had a very slow adoption. Dentistry is also faced with dramatic “variation in dental practice”--a term suggesting that different practitioners will recommend strikingly differing treatments for the same condition in the same patient. This was illustrated in the Reader’s Digest report several years ago in which an investigative reporter sought treatment plans from 50 dentists in 28 states and received treatment estimates ranging in cost from $700 to $29,850.

Several strategies have been employed to transfer new knowledge and to reduce variation within the health professions. The evidence-based movement of the 1970s is among the most popular strategies. The academic community has showcased the systematic reviews, such as those provided by the Cochrane Collaboration, but they have had minimal impact on clinical practice.

Several limitations of the evidence-based movement have been identified. There is insufficient research to establish clear, prescriptive guidelines for most clinical situations. Well-controlled RTCs may document efficacy but not effectiveness of a treatment. Also, practitioners are skeptical of complex RTCs. The evidence-based movement has alienated some practitioners who felt they always practiced in accordance with the best evidence. And finally, treatment recommendations generated by some clinical trials are at odds with economic interests of private practice.

Other science transfer strategies have been established to speed the incorporation of new scientific knowledge into clinical practice, including web-based CE, practice guidelines, NIH consensus statements, and state-of-the-science reports. All of these are certainly well intentioned, but the evidence is that the impact of these science transfer strategies on the typical practitioner is limited.

Dr. Rugh provided 15 proposed reasons why science transfer efforts have not been as successful as their advocates had hoped. These include:

* The increasing isolation of scientists & clinicians.

* Dentistry’s mechanical vs. biological orientation.

* Competing interests (e.g., OSHA, HIPAA, etc.).

* Practitioners mistrust of researchers and science.

* Negative impact of new knowledge on income.

* Office staff resistance to change.

* Information explosion/overload.

* Science outcomes often unclear (dueling PhDs, “Science Babble”)

* Clinicians value personal experience rather than published research.

* Bad early experiences with new procedures/products (e.g., sealants).

* Competing knowledge sources (non-refereed journals and newsletters).

Dr. Rugh noted that many efforts are primarily educational in nature. These efforts focus on communicating results to practitioners. He suggested that increasing emphasis should be placed on behavior change, rather than information exchange. He also noted that dentistry is a business and that researchers need to be aware of the economic contingencies that affect clinicians.

Managed care, direct public marketing, and targeting early adopters are among the strategies that have been proposed to hasten science transfer. Dr. Rugh noted that large pharmaceutical companies have used direct marketing to create “patient pull” on providers. The availability of new medications is heavily advertised to the public who are encouraged to “ask your doctor.” Although very expensive, direct marketing does impact practice behaviors. Third-party payers and HMO reimbursement plans also have a dramatic impact on practice behaviors. Finally, targeting “early adopters” with new technology and new knowledge may speed the transfer of the knowledge into the practice community. However, Dr Rugh concluded that if the goal is improved oral health for the general public, legislating public health measures are probably more effective than a focus on science transfer to individual practitioners.

In his view, transfer of new knowledge to practitioners and to the public will continue to be a very slow process until scientists take a more active role in facilitating that transfer. Scientists may need to become more “political” in the sense of advocating (even marketing) new science and new knowledge to insurance companies, industry, legislators, the practice community, and the public.