Joining the dots between the clinical and the evidence

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As a newly graduated speech and language therapist working with real life people I always endeavoured to apply what the research literature or expert guidelines advised. At this point I understood that the most effective interventions were those that had been tried and tested and shown to work. This seemed a foolproof plan for clinical practice.

However I quickly (perhaps within a month or so) found that the people of Barking, Dagenham and Havering didn’t fit this plan. My first job as an SLT was in Barking and Dagenham and it was a great initiation to people. People are frequently much much more complicated than I had expected as a student. Yet I was well prepared; best practice also means being person centred. Thus there were frequently many people for whom I could not simply apply what I had read. I would take one element from one paper and a recommendation from somewhere else and I would cook up the most appropriate intervention plan using this dynamic clinical judgement.

Yet by the time I began working in complex brain injury and memory disorders at South London and the Maudsley I confess I would sometimes wonder if what I was doing bore any relationship at all to evidence based research. The people I worked with here were incredibly complex, with layers of difficult medical and social dynamics to be considered.

I realised that as our population ages and society evolves individuals also become more intricate. We are collecting more diseases; meaning people frequently present with many co-morbidities making it even harder to find the research to match that individual for evidence based care. We are also more socially complex; we own more houses, we have more money (to spend on drugs and alcohol), we are more educated and we have more opinions (often from dubious internet based resources). How do we choose the best interventions for the person, their multiple medical issues, their families, carers and financial/housing situation…..

In this respect I would say that clinical practice is often well ahead of research and clinical guidelines. Clinical practice can be and has to be flexible and creative. Often the research to back up what clinicians consider intuitive takes some time to catch up. Yet research can make incredible leaps and we also find it is difficult to change to clinical practice. They say that it takes 8 years for recommendations from research to be integrated in clinical practice.

So I say that as clinicians we must open our arms to research. We must also leap into the unknown and attempt to create the research and guidelines to support what we do. Experienced speech and language therapists (and many other allied health disciplines) often underestimate their own expertise. Join a committee, write a guideline, a policy or do a piece of research. No matter how big or small our voices count. And on paper they count even more. Be open to change both as a clinicians reading research and a clinician doing research or setting research agendas.

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