clinical expertise: where would we be without it? ronnie detrich

Clinical Expertise: Where Would We Be Without It?

Ronnie Detrich

Questions

• How many decisions do you make in a day?• Of those decisions, how often do you consult the

research literature?• If not consulting research literature what is basis for

decision?

The Clinical Problem

• Practitioners must make many decisions every day about services for clients.

• There is an ethical responsibility to make decisions in a way that most likely improves outcomes for clients.

• What is to be the basis for those decisions? Expertise is necessary and inevitable.

Definition of Evidence-based Practice

• Evidence-based practice:a framework for decision makingdesigned to improve outcomes for clients

• Evidence-based practice is the integration of: best available evidence, clinical expertise, client values and context,

as a basis for decision-making.

Best Available Evidence

Client Values & Context

Clinical Decision

Clinical Expertise

Available Evidence

Client Values & Context

Clinical Expertise

Clinical Decision

Best Available Evidence

Client Values & Context

Clinical Expertise

Clinical Decision

Available Evidence

Clinical Expertise

• To date, most of the attention has been given to best available evidence.

• Goal today: understand what clinical expertise is, the necessity and inevitability of it,and the limitations of it.

What is Clinical Expertise

Clinical expertise: competence attained by psychologists through education, training, and experience that results in effective practice.

(APA Task Force, 2006)

Why Clinical Expertise is Necessary

“Evidence doesn’t make decisions, people do.”(Haynes, Devereaux, Guyatt, 2002)

“The formalized experience of science, added to the practical experience of the individual in a complex set of circumstances, offers the best basis for effective action.”

Skinner (S&HB, 1953)

Why Clinical Expertise is Necessary

“When we do not know, we guess. Science does not eliminate guessing, but by narrowing the field of alternative courses of action it helps us to guess more effectively.”

Skinner (S&HB, 1953)

Clinical expertise is not the enemy;It is the means by which evidence contacts clients.

Why is Clinical Expertise Inevitable?

• All clinical problems are contextual.

“Clinical expertise is used to integrate the best research evidence with clinical data (e.g., information about the patient obtained over the course of treatment) in the context of the patient’s characteristics and preferences to deliver services that have a high probability of achieving the goals of treatment.”

APA Task Force, 2006

Why Clinical Expertise is Inevitable

“In those instances where more than one scientifically supported treatment has been established, additional factors may be considered in selecting interventions, including, but not limited to, efficiency and cost-effectiveness, risks and side-effects of the interventions, client preference, and practitioner experience and training.”

BACB Professional and Ethical Compliance Code 2.09c

Why Clinical Expertise is Inevitable

“Clients have the right to effective treatment (i.e., based on the research literature and adapted to the individual client).”

BACB Professional and Ethical Compliance Code 2.09a

Why Clinical Expertise is Inevitable

“The type of assessment used is determined by clients’ needs and consent, environmental parameters, and other contextual variables.”

BACB Professional and Ethical Compliance Code 3.01a

Why Is Clinical Expertise Inevitable?

• Practitioners always work under conditions of uncertainty.No outcomes are certain.

“The application of research evidence to a given patient always involves probabilistic inferences.”

(APA Task Force, 2006)

Components of Clinical Expertise• Ethical practice• Knowledge of the research literature and its

applicability to particular clients• Incorporation of the conceptual system of ABA • Breadth and depth of clinical and interpersonal

skills• Integration of client values and context • Recognition of the need for outside consultation• Data-based decision making• Ongoing professional development

Slocum, et al., (2014)

Limits to Clinical Expertise

• Humans are flawed decision makers.

“Whenever psychologists involved in research or practice move from observations to inferences

and generalizations, there are inherent risks of idiosyncratic interpretations, overgeneralizations, confirmatory biases, and similar errors in judgment.”

APA Task Force, 2006

• “Biases” are efficient and often correct. Trouble comes when they are not critically examined.

Experience is Not Enough

• Systematic review of physicians (Choudhry, 2005)62 studies reviewed.2% reported increasing performance with increasing years

of experience.21% reported no association between experience and

outcomes.52% of studies reported decreasing performance with

increasing years of experience across all outcomes. In sum, 73% of studies showed increasing experience was

either negatively or unrelated to positive outcomes.

Variables Influencing Clinical Expertise

Variables That Influence Clinical Expertise

Clinician History

• History of reinforcement and punishment for clinical behaviors

• Professional values (i.e., outcomes that function as reinforcers)

Experience alone is not sufficient for establishing clinical expertise (Dawes, 1994; Tracey et al., 2014)Deliberate practice (Ericsson, 2006)Availability of accurate feedback (Shanteau, 1992)

Variables That Influence Clinical Expertise

Client Outcomes

Client outcomes may reinforce or punish particular clinical behaviors

e.g., relying on parental report to identify reinforcers vs. conducting a preference assessment

But, clinicians may vary in sensitivity to client outcomes as consequences

Personal history, clinician history, rule-following (Hayes et al., 1986)

And, consequences are not optimal for shaping behavior Client outcomes are often delayed Often not a direct, causal relation between one clinician behavior

and a client outcome

Variables That Influence Clinical Expertise

Organizational Context

• Establishes motivation What outcomes are reinforcing?

• Sets rules and contingencies that can support or hinder clinical expertise and ethical practice “One size fits all” assessments and curricula Number of clients on caseload Available resources, access to research Use of decision-making flowcharts Data shares and feedback on decision-making

Geiger, Carr, and LeBlanc (2000)

Variables That Influence Clinical Expertise

Personal History

• History of reinforcement and punishment that shapes personal values (i.e., reinforcing outcomes)

• Influences receptiveness to principles of behavior and ethical standards of ABA

“Spare the rod, spoil the child” “You can catch more flies with honey than vinegar”

4.08a: Behavior analysts recommend reinforcement rather than punishment whenever possible. Professional and Ethical Compliance Code for Behavior Analysts (2015)

Variables That Influence Clinical Expertise

Training Program

• Preservice Training Coursework

Quality and quantity Rules (e.g., definitions and prescriptive recommendations) Contingencies (case-based learning, decision-making practice)

Supervised Experience Implementation of assessments and interventions Repeated application of decision-making in context Explicit feedback

• Continuing Education Contact with research and evolving ethical standards *Most do not have elements of deliberate practice

Variables That Influence Clinical Expertise

Behavior Analyst Certification Board

Direct and indirect influences on clinical expertise at various levels•Content standards: Task list, exam•Approval of course sequences and university supervision practica•Ethical and disciplinary standards•Supervision standards•Continuing education requirements

Variables That Influence Clinical Expertise

State and National Organizations

• Additional content standards and ethical guidelines for personnel preparation

• Conferences for ongoing professional development*Most do not have elements of deliberate practice

• Advocacy

Variables That Influence Clinical Expertise

Laws, Policies & Insurance Requirements

May constrain, or set the occasion for, organizations to support clinical expertise

Funding and reimbursement ratesMandated or prohibited assessments and practicesNumber of hours prescribed/reimbursed

Developing Clinical Expertise

Developing Clinical Expertise

• Minimum of 10 years of intense practice to develop expert performance.

• Deliberate practice: Immediate informative feedbackKnowledge of resultsRepeatedly perform the same or similar tasks

(Ericsson, Krampe, & Tesch-Romer, 1993)

Developing Clinical Expertise

• Create organizational culture that support decisions incorporating best available evidence and client values and context

• Create opportunities for deliberate practice in Specific clinical skills Decision-making

• Training programs/organizational contexts Set the occasion for explicit decision-making (“think-aloud”) Give immediate feedback Evaluate effects of the decision Incorporate decision aids

Developing Clinical Expertise

• BACB Recent changes: Task list update, ethics course, ethics

CEUs, enhanced standards for supervisionPossible considerations: Incorporate deliberate practice

• Laws and policiesProvide adequate reimbursement to enable reasonable

caseloadsRequire person-centered planning or family priorities in

treatment plans for reimbursement

Final Thoughts

• The necessity of clinical expertise does not mean that it can be substituted for best available evidence and client values and context.

• The flaws of clinical expertise does not mean we can ignore or eliminate it.

• The best path forward is to improve it.

Client Outcomes

Client outcomes may reinforce or punish particular clinical behaviors

e.g., relying on parental report to identify reinforcers vs. conducting a preference assessment

But, clinicians may vary in sensitivity to client outcomes as consequences

Personal history, clinician history, rule-following (Hayes et al., 1986)

And, consequences are not optimal for shaping behavior Client outcomes are often delayed Often not a direct, causal relation between one clinician behavior

and a client outcome

Clinician History

• History of reinforcement and punishment for clinical behaviors

• Professional values (i.e., outcomes that function as reinforcers)

Experience alone is not sufficient for establishing clinical expertise (Dawes, 1994; Tracey et al., 2014)Deliberate practice (Ericsson, 2006)Availability of accurate feedback (Shanteau, 1992)

Clinician History

• History of reinforcement and punishment for clinical behaviors

• Professional values (i.e., outcomes that function as reinforcers)

Experience alone is not sufficient for establishing clinical expertise (Dawes, 1994; Tracey et al., 2014)Deliberate practice (Ericsson, 2006)Availability of accurate feedback (Shanteau, 1992)

Developing Clinical Expertise

• Cannot eliminate it/wish it away.• CE is imperfect basis for making decisions.• If clinical expertise is necessary, inevitable, and

unreliable how do we improve it?• Are judgments getting made in a disciplined expert

fashion or are they being influenced by idiosyncratic variables not controlled by BAE and client values and context?