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"Know What" and "Know How": Knowledge Creation in Clinical Practice

¹ dsm-Forsyth Center for Evidence-Based Dentistry, The Forsyth Institute, 140 The Fenway, Boston, MA, and Health Policy & Health Services Research, Boston University Goldman School of Dental Medicine, Boston, MA 02114, USA; and
² Institute for Healthcare Improvement, 20 University Road, Cambridge, MA 02138, USA, and University of Glasgow Dental School, 375 Sauchiehall Street, Glasgow, G2 3JZ, UK

^* corresponding author, rniederman{at}forsyth.org

KEY WORDS: knowledge translation • knowledge creation

We believe that the time has come for oral health research, and in particular the practice-based research networks (PBRNs), to begin implementing research protocols that address "know what" as well as "know how", forging a link between the two, and catapulting oral health care into the 21st century.

"Know what" is sometimes defined as "explicit knowledge". Knowing what works in clinical trials and clinical practice, and efficacy and effectiveness, respectively, are two examples of explicit knowledge. Connecting efficacy and effectiveness requires "know how", or so-called "tacit knowledge".

Consider the following: Almost 100% of clinical research is done in academic centers, on very selected disease entities, in a very homogeneous subset of patients (0.1% of patients) (explicit knowledge of efficacy). However, this homogeneous patient population is very different from the very heterogeneous 99.9% of patients and problems primary care clinicians see where effectiveness is truly measured (e.g., Green, 2001). The implementation of new concepts, the "know what" from efficacy trials, may ultimately prove to be very effective in a heterogeneous population. However, the "know how" to deliver this care to a heterogeneous population may be unknown. A trivial question highlights the problem: Is a cancer cure with an efficacy of 100% truly 100% effective if it can be delivered to only 10% of the population?

Developing "know how" and moving dentistry into the 21st century could be a key goal of the PBRNs. The three US PBRNs, with a 2005 commitment of $75 million from the US Government, and multiple PBRNs in Europe and Australia, offer a unique venue to initiate this "know how" process.

The challenge will be to develop and implement sustainable 21st century systems for oral health care that address the needs of both the well-to-do and the underserved, during a period of diminishing resources and increasing costs. This is particularly true in oral health, where clinicians rapidly incorporate new techniques (e.g., high-speed handpieces, NiTi drill bits, dental implants), but are slow to adopt new concepts (e.g., treatment of caries infections with silver diamine fluoride) (Llodra et al., 2005).

We see three hurdles to surmount in creating clinical "know how":

1. Overcoming a historical bias. For over 100 years, dentists have successfully treated caries and periodontal disease with three metals: silver, gold, and stainless steel. But based on research that is 30 years old, we know that caries and periodontal disease are infections (e.g., Gibbons and van Houte, 1975). Interestingly, no medical doctor would treat these infections (or any infection) with any of these metals.
   Dentists, however, continue to use these metals as their primary therapeutic intervention for two reasons: First, an embedded and integrated infrastructure of education, licensing, Boards, re-imbursement, corporate insurance purchasing, and public perception motivate stakeholders to do so. The stakeholders who manage these infrastructure systems know what caries and periodontal disease are, but lack the know-how to change these systems.
   
2. Some stakeholders, in contrast, may not know what to believe. With ~ 500 clinical trials/year/dental specialty, increasing at 10% per year (Niederman et al., 2002), clinicians and educators, as well as insurers and insurance purchasers, are overwhelmed with clinical information (some of which is apparently conflicting). Information users, therefore, defer to what they have always done (Redelmeier and Shafir, 1995). They apparently lack the know-how to identify, obtain, evaluate, distill, and implement this evidence-based information in practice.
   
3. As health care demonstrates, it can take more than 15 years for clinical systems to incorporate new and effective concepts into routine practice (e.g., Lau et al., 1992). The 2005 Nobel Prize in medicine, for identifying H. pylori as the causative agent for ulcers, highlights this phenomenon. This bacterium was identified in the early 1980s. Fifteen years later, the National Institutes of Health issued a consensus statement indicating that ulcers should be treated by bacterial eradication. Yet, in 1996, 96% of US prescriptions for ulcers were for symptomatic, not curative, treatment (O’Reilly, 1997).
   

Against this historic tradition, the US, European, and Australian PBRNs could become engines of clinical knowledge creation—IF they conceptualize themselves as "learning organizations", that is, organizations that create, acquire, and transfer "know what" and "know how", and model clinical behavior that reflects new knowledge and insights (Griffiths et al., 2000; Fenton et al., 2001).

This approach to knowledge creation is experimentally based. However, the experimental modalities for "know why", "know what", and "know how" are quite different (Tables 1, 2) (adapted from Langley et al., 1996). Yet, all three methods for creating knowledge are derived from Sir Francis Bacon’s scientific method.

More importantly, over the last 20 years, the Institute for Healthcare Improvement (IHI) (www.IHI.org) and the National Initiative for Children’s Healthcare Quality (NICHQ) (www.NICHQ.org) have successfully developed and employed know-how that improves healthcare quality. Guidelines for the conduct and reporting of these improvement trials are now being codified (Davidoff and Batalden, 2005). As well, BioMed Central, in 2005, announced publication of a new healthcare journal, Implementation Science, an open-access online journal, "...to promote the uptake of research findings into routine healthcare in both clinical and policy contexts".

We believe that the time has come for dentistry to develop and employ translational know-how, and we believe that the PBRNs can lead.

ACKNOWLEDGMENTS

We thank the Dental Service of Massachusetts and the UK Health Foundation for their generous support of this work. We also thank Rodrigo Marino for critically reviewing this editorial and offering insightful improvements.

Received November 1, 2005; Last revision December 24, 2005; Accepted February 13, 2006

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