Think beyond the evidence Pritpal S Tamber, Optimising Clinical Knowledge Ltd 2 July 2012 Dear Editor, I applaud the authors¿ summary of research findings in knowledge translation. I agree that syntheses are the best form of knowledge for clinicians to work from but in many specialities they simply do not exist - sometimes because the primary studies are insufficient to warrant a summary. This is something we encountered at Map of Medicine (at which I was Medical Director) when we created the content. We relied on guidance producers and systematic reviews as the main form of knowledge to work from, but we often found that either specific specialties, topics or parts of topics were insufficiently covered by them. Our solution was to do a light-Delphi process, which we established through professional bodies, such as Royal Colleges and specialist societies (this also leveraged their status as key opinion leaders, another point in your article). In your list of barriers I was surprised not to see time specifically mentioned. I suspect it's implicit to many of things listed but my experience suggests that it is more important than any other. Most doctors are conscientious individuals who, with more time, would make greater efforts to apply new knowledge into their practice. Indeed, I think most clinicians are hungry for new knowledge, even if only to reduce their medico-legal risk. However, with general practitioners (primary care physicians) in the UK only having, on average, 8 minutes per patient there simply is not the time to acknowledge what one's questions are and then seek answers for them, either intra- or post-consultation. I had not heard of the Proteus Phenomenon but I suspect we saw an aspect of that playing out in Faculty of 1000 Medicine. We had an option in the service whereby Faculty Members could say whether an article changed their practice. We assumed that it would be used very rarely and that when used it would be for big, blockbuster papers in The Lancet or NEJM. Instead what we found was that the 'changes practice' option was ticked on smaller studies, usually confirmatory ones and not necessarily traditionally-rigorous study designs such as randomised, controlled trials. We found the Faculty often waited until they felt there was sufficient confirmatory evidence before they suggested that practice should change. In your table 1, I disagree that population health is not relevant to consumers and professionals. I don't know the impact of the global financial crisis in Canada or Australia (where some of the authors are from) but in England there is an attempt to reduce the annual healthcare budget by over 20% by 2015 (the initiative started late 2010). This flies in the face of the increasing expectation of consumers for more healthcare, and faster. While it is politically unpalatable to use the word 'rationing', it's clear that some form of rationing is going to be required to meet the cost-reduction target. That is only likely to happen if both clinicians and the public understand the financial pressures on healthcare and the rising need for out-of-pocket expenses or supplementary insurance. I also think that industry is increasingly aware of the need to provide value across populations. In England, this is being potentiated by the debate on value-based pricing and the evolving role of the National Institute for Health and Clinical Excellence (NICE). In my work I am hearing of more and more pharmaceutical and device companies asking themselves how their products can offer value beyond the specific intervention they offer. In behaviour change strategies, I find the role of content to be repeatedly underplayed. All of the interventions listed in table 3 have content at their heart and yet there is little appreciation of what it takes to write compelling content. This is not about great literature, but about consistent messaging, whether delivered in printed, educational materials, through educational meetings or by local opinion leaders. Too often the different channels used do not align. Indeed, I am currently in discussion with a local primary care practice trying to convince them to implement a 'content intervention' across the practice aligned to their two or three primary goals for the year. The idea would be to align all information across all channels and remove all non-aligned content from the practice (leaflets, website info, etc). I have no doubt that this would yield a significant, measurable quality impact. Much of knowledge translation can come down to messaging and PR (public relations). As you know, there is an industry dedicated to this, with specialist sectors for business-to-business and business-to-consumer companies. I am always surprised that healthcare feels the need to reinvent the wheel through the prism of research and evidence when best practices are established elsewhere. Throughout your article I found elements of what I know PR firms do, such as never delivering more than three messages in 10-15 minutes presentations or having different kinds of people speak to different audiences. Indeed, a physician friend of mine created a service solely dedicated to finding the right kind of key opinion leaders, by topic and geographical area, to speak to different audiences. It¿s interesting that his customers are mainly pharmaceutical companies rather than healthcare providers. My final comment - which is beyond the scope of your article - is how little strategy there is in how content is delivered. The problems in knowledge translation are not new and yet when a healthcare provider decides it wants to focus on a specific issue it rarely does the work needed to think through what it means for the communications it creates or permits (such as the type of education clinicians should receive). I have always found this baffling. In commercial business it is now established practice to align the brand, its values, the strategy and all communications to all stakeholders and across all channels. I fail to comprehend why healthcare believes itself to be different. It is not. I want to thank you for your excellent summary. I hope the next time such a summary is written, you ¿ or other authors ¿ are compelled to look beyond research and evidence and find best practices from other industries. Pritpal S Tamber Competing interests I provide consultancy to organisations to help them make better use of established knowledge, which can include many of the strategies and themes mentioned in the article and in my comment. I helped one of the authors (ME), who is also the Editor-in-Chief, launch this journal in my former role as the Editorial Director for Medicine of BioMed Central. This comment was first created as a personal communication to the authors who asked me to submit it to the journal as a comment.