A New Focus on Implementation Science with Sara Becker, PhD, and Rinad Beidas, PhD

 Erin Spain [00:00:10] This is Breakthroughs. A podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, host of the show. To have the greatest impact on human health, biomedical research findings and other evidence based practices need to be implemented into routine health care. Implementation Science is a relatively new field dedicated to this mission. Two new faculty at the Feinberg School of Medicine are experts in this field, and they join me to talk about their work and how they plan to advance the impact of implementation science and grow the field here at Northwestern. Welcome to the show. Dr. Rinad Beidas, the new chair of Medical Social Sciences at Feinberg, and Dr. Sara Becker, professor of psychiatry and director of our newly formed Center for Dissemination and Implementation Science. 

Sara Becker, PhD [00:01:05] Thank you so much for having us. 

Rinad Beidas, PhD [00:01:06] Really excited to be here with you both today.   

Erin Spain [00:01:09] So implementation science, this is a relatively new field, but it was identified as a new research priority for Feinberg just this year. So, Dr. Becker, start us off today. Tell me, what is dissemination and implementation science broadly? 

Sara Becker, PhD [00:01:25] Broadly speaking, dissemination and implementation science is the study of intentional and proactive methods to bridge the gap between what we know in terms of public health and medical knowledge and what we actually do in terms of public health and medical practice. When you hear about this gap, oftentimes in the literature or in the public conversation, we talk about that as a singular thing. Really, we're addressing at least two major gaps in tandem, and those are addressed by the two words in dissemination and implementation science. We can think of dissemination science as work to address the public health demand gap, defined as the gap between those who actually need some sort of health care or service and those who actually receive any at all. And then implementation science is really the work to actually increase the supply of such services in biomedical community and clinical care contexts. And so the work to actually get the treatment that we know works and the health care that we know works out to usual care settings.  

Erin Spain [00:02:27] And tell me a little bit more about how Feinberg has made this a research priority. 

Sara Becker, PhD [00:02:31] Well, before Dr. Beidas and I were fortunate enough to join the Feinberg community, there was an all faculty strategic retreat where it really became apparent that this was one of the most important priorities for faculty and attendance. It actually bubbled up during a faculty brainstorming exercise. And I really want to publicly thank Dean Nielsen for hearing that feedback and really making it a priority for Feinberg to invest in this space and support faculty by really leaning into the methods to bridge the gap from research to practice. 

Erin Spain [00:03:02] Dr. Beidas, I want you to talk a little bit more about this, the research to practice gap. Why is there such an overwhelming gap between evidence based practices and their incorporation into everyday health care? Why do you think this issue has come into focus now, especially given that this is a relatively new field? 

Rinad Beidas, PhD [00:03:19] I would say actually that the gap between research to practice is not a new phenomenon. This has been going on for a long time. And actually, while implementation science as a strategic priority is perhaps a new initiative for Feinberg, implementation science as a field has really been coalescing and has come into its adolescence. People have been doing work in the space for about 20 years and then before it was called implementation science, people were doing work in this space as well. There's a lot of reasons for the research practice gap. One is that many of our evidence based practices or things as we often call them, because they can be interventions or programs or policies or procedures are developed outside of the context in which they're meant to be delivered. In the absence of having partner or stakeholder feedback about how they might fit or how acceptable, appropriate or feasible they are for that setting. One of the things that is really important for us to be thinking about is incorporating this way of thinking and methods from implementation science much earlier in the translational pipeline so that we don't get to the end of the road and then say, “Oh, we've developed this thing that works in very controlled settings but can't work in the real world.” So I think that's a major driver. A second major driver is we just haven't invested enough in thinking about how to take scientific discoveries and actually implementing them. So there was a paper that came out a few years ago looking at the percentage of the National Cancer Institute budget that goes to implementation research, and they've been real leaders in pushing forward an agenda around implementation research. And it's still less than 1% of their overall budget. So we spend so much money on discovery, and that's amazing. And we have so many discoveries that could change people's lives. But we don't invest the same care, attention or resources into the actual process. And the last point I'll make is I think COVID 19 has really highlighted for us why implementation is so important. There was this paper that came out in 2020 in Health Affairs by Paul Toole and colleagues, and it was a simulation study before the vaccine had received its emergency use authorization. And what they showed was that the implementation factors would be as relevant for the success of the vaccine as the actual biological efficacy of the vaccine. And we saw that played out and continue to play out over the past few years. So it's multifactorial and it's going to require multilevel approaches to an investment. 

Sara Becker, PhD [00:06:01] Something I would add is that I think in academia we often adapt the field of dreams approach of if you build it, they will come. And I think the predominant approach is, as Dr. Beidas was saying, this emphasis on discovery and then this assumption that if we simply publish our work and put it in peer reviewed journals, that that will be enough to get it out into the field. And I think we've really very clearly received the message over the last decade or so that that approach is not effective and that we really need to be intentional and need to be proactive about accelerating our pipeline to get things out. 

Erin Spain [00:06:36] I'm wondering, is there some change management that has to be done inside academia with the folks who are doing the research and how do you approach that? 

Sara Becker, PhD [00:06:45] I love that you asked a question with the phrase change management because I became interested in this field through business, and that's what it's called there. So just as Dr. Beidas was saying. There's been a cadre of folks doing this work in academia. There's also been folks doing this work outside of academia in other settings engineers, business folks, marketers, you know, doing this type of work. And I think one of the key challenges ahead of us is to really bring people together and ensure that our interdisciplinary approach, you know, is using language that everyone can understand and that we're all kind of going in the same direction. I do think a change management approach is needed within academia in the sense that earlier in people's training we need to be emphasizing these interdisciplinary methods and the fact that we must right up front throughout our translational pipeline. As soon as you're even thinking about what to target, when you're thinking about a signal of whether a health service works. You have to be thinking about the context and you have to be thinking about the end user and making sure not only that something works, but that it's helpful and that it's relevant to that context where you're aiming to deliver it. And that really does require a fundamentally different way of thinking. 

Erin Spain [00:07:54] And I'm sure that there are folks who are the payers for biomedical research. I mean, the public, the government, other folks, private groups, they must be concerned over this lack of the public health impact of their research dollars. Would you say so? 

Rinad Beidas, PhD [00:08:08] Yeah. I mean, I think that's why we've seen so much of a kind of awakening to the field of implementation science. There's lots of funding opportunities and the real challenge we have in the field now is around capacity. There's just not enough implementation scientists at the table. I've seen a huge change in the past five years. It's really exciting. You know, I've been at this now for 17 years and when I started, people would kind of look at me funny and be like, What are you talking about? What do you do? But in the past five years, people are seeking us out and really wanting to apply these approaches. So I already really feel a sea change. But at the same time, I don't feel like the public knows about what implementation science is. And I've only seen one op ed in a popular press kind of setting that came out in 2020. It was from the Princess of Jordan. She mentioned implementation research in a CNN op ed, and I jumped out of my seat and I was so excited. But I think that, you know, even in thinking about COVID 19 response, you know, there weren't implementation scientists necessarily at the table talking about how to bring insights from implementation science to address our pandemic response. And so while I think we've made great strides in the academic community and I see the landscape really shifting from a funding perspective, and I think Northwestern is a leader and seeing it as being a strategic priority for the medical school. Last year there was an editorial published in Science calling for a New Lane for Science by Dr. Enola Proctor and Dr. Alvin Guang. I think we've arrived in the scientific world, but I want to make sure we have parallel efforts in the public and that people implementation science becomes a household word. 

Erin Spain [00:09:54] Let's talk about something else in the world of implementation science, and that's implementation science and health equity. What role can implementation science play in order to further greater equity in health care? 

Sara Becker, PhD [00:10:07] Erin, I love this question because I think when you look to the implementation science literature, equity has been an implicit focus at a lot of the work that's been done. And in recent years we're seeing this awakening and this realization that equity really needs to be explicit in the frameworks, models and measures that we use in the field to ensure that equity is really front and center in the work that's done. I would say quite simply that implementation without attention to inequity is really likely to exacerbate disparities. And I think, you know, Dr. Beidas has really been sounding the drumbeat of just pointing to the COVID pandemic as really highlighting these issues that was such an example of attention to try to get out the supply of vaccines without attention to equity. And we saw disparities increase as a result because those that were most able to go and get the vaccine were the ones most likely to benefit. And we didn't see an intentional and really specific focus on rising up, you know, the folks that most need help accessing treatment. And so I would say that implementation science can help with equity if we're intentional in our use of implementation science methods of making certain that the strategies that we use, the measures and the outcomes that we use are really focusing on those that are most disadvantaged, most minoritized and most ignored by the existing systems. Because if we focus on implementing to those populations, then we're likely more likely to see greater population health than if we focus on the general population without being really intentional. 

Rinad Beidas, PhD [00:11:42] I think that's such an excellent question, and I completely agree with Dr. Becker. For many years, implementation science was quiet about equity matters. In my own work, doing work in the public behavioral health system in Philadelphia. Equity was always kind of baked into my thinking and the approaches that we took. But if you looked at the frameworks that the strategies at the outcomes, there really wasn't a whole lot of emphasis on thinking about inequities and implementation can actually serve to create new inequities if we're only implementing in well resourced environments or to reify existing ones. And so following the murder of George Floyd and the racial reckoning in the United States over the past few years, there have been a number of seminal papers that have called out the need to draw from the rich and long tradition of health equity research into to weave together approaches into implementation science. And we're starting to see a lot of forward movement. We have frameworks now that incorporate an equity lens and operationalized approaches to carefully and prospectively ensure that implementation does not create new inequities or reify existing ones. So we've come a long way and there's still a long way to go. 

Erin Spain [00:12:57] Dr. Beidas, tell me a little more about your research broadly and some of the insights you bring from implementation science into your work. 

Rinad Beidas, PhD [00:13:06] For me, implementation science is an opportunity to move the needle equitably in health to advocate and amplify for our communities and to pursue social justice and population health. And so I am always so excited to wake up every morning and to think about how the work that our group and other groups are doing allow us to move towards that vision. I have had the great honor of doing this work in a number of different areas, so I'm trained as a child clinical psychologist, and I actually went to graduate school planning to develop new treatments for pediatric anxiety. But as I was training, I began to observe this pattern that really kept me up at night where kids would come to our research-based clinic having received treatment in the community that wasn't in evidence-based practice, often hopeless and sure that psychotherapy could ever work for them. And then when they received an adequate dosage of cognitive behavioral therapy, which is the gold standard treatment for pediatric anxiety, they would usually respond well to treatment and be able to go on and live their life aligned in a way with their values and their hopes. And so I made this drastic pivot in graduate school from wanting to study the efficacy of newly developed interventions for anxiety, to wanting to understand why clinicians in the community weren't using evidence based practice. Now, most people start with training as being the mechanism through which to change clinician behavior, like that is our gut instinct. Oh, someone's not doing something well, it's probably cause they don't know how, they don't have the knowledge. And so my first study was really focused on what are the best ways to train clinicians in cognitive behavioral therapy for pediatric anxiety. In that work, I came to recognize and came, became more familiar with the fields, that there is multi-level reasons for why people don't do evidence based practices. They might not have the knowledge patient might not want that particular evidence based practice. The organization may not support the delivery of that particular practice. It may not be reimbursable at the system level. And so I went from thinking about how best can we train clinicians to funneling out to this kind of multilevel perspective on what makes it possible to implement evidence-based practices. That then led me down a ten year partnership with the City of Philadelphia, Department of Behavioral Health. They were engaging in a large scale implementation natural experiment where they were implementing evidence based practices across their large public behavioral health system, serving 150,000 people annually. And I had the great opportunity to study what happens in a large public behavioral health system when there's a centralized infrastructure to support, reward and incentivize evidence based practice. From there, I started to collaborate with colleagues in lots of different areas and began to work in cardiovascular disease and HIV, in cancer. And what's really interesting is that the challenges that make implementation difficult are kind of ubiquitous across content areas. And the key is really to understand the context and what is getting in the way or what makes it possible to implement and then to design and test strategies. We call those implementation strategies to implement those practices. And at this point in my career, I'm really excited about approaches and implementation that make it easier for clinicians to do the right thing and for organizations to make it easier for clinicians because after a lot of time in health systems and in under-resourced public settings, what I realized is that often our implementation approaches make it harder for people. And so that's how I became interested in bringing insights from behavioral economics to nudge clinicians to make it easier for them within the context of their workflow and daily practice. So it has been a humbling journey over the past 17 years, and it's been a lot of fun, kind of following the threads toward how do we transform health and health care delivery equitably in a way that maintains the wellness of care teams and clinicians and ensures that everybody has appropriate access and high quality care. 

Erin Spain [00:17:36] Dr. Becker, I want to hear about your research as well. And something that's interesting about both of you is that you both have a background in psychology. You're both clinical psychologists. How did you end up, Dr. Becker Going from psychology to implementation science. And tell me about your research as well.   

Sara Becker, PhD [00:17:52] I actually was a double major in psychology and economics over 20 years ago and went from undergraduate thinking that I wanted to take that training in a business lens. And so my first position out of undergraduate was actually working as a strategy consultant for one of the big three strategy consulting firms. And there I was in the change management practice area and the healthcare and biotechnology content area, which meant that all of the projects that I did for a few years were large scale organizational change initiatives with pharmaceutical and biotechnology companies. And so I was essentially implementing things and doing implementation practice but through a business lens. And it was at that point when working with healthcare companies and doing organizational change that I decided to take a bit of a pivot in my career and go back to academia. I had really loved the training that I'd had an undergraduate. I missed the direct patient contact, so I applied for my clinical psychology Ph.D. at that time, and it was so jarring to go into graduate school and get really intensive training about how some health services were more effective than others. But to have everything I'd learned in business be completely absent. So I was in these classes learning, Oh, this treatment's more effective than others. What's our marketing strategy? You know, what's our outreach approach? How are we going to actually get organizations to think about this? And that was just completely missing from my training. And so clinically, the population that I have always enjoyed working with and that I still have a real fondness for our youth with substance use and mental health issues. So from graduate school, I went to a postdoctoral fellowship, a center that studied addiction based at Brown University. And when it was time to write my first grant there, I thought, Can I try to integrate these business principles that I learned in practice now into this field to try to improve access to care? And so I wrote training goals without knowing any of the vocabulary in this field. And so I wrote training goals to learn about change management and training goals to do direct to consumer marketing. And it was at that time. In 2011 that the NIH had its first training Institute for Dissemination and Implementation Research in Health. And I remember reading that announcement in 2011 and thinking, Oh my goodness, this is what I'm trying to do. I know this says and I will say, I was very fortunate to be at that training with Dr. Beidas, Dr. Hendrix Brown, who's really internationally known in this space as well, also at Northwestern Feinberg School of Medicine, I believe, gave a lecture on his work doing cluster randomized trials and community settings. And so that was really the aha moment for me of realizing, you know, these are the methods that I'd like to use. This is the language that I'm trying to use in my work. And since that point, I've really been an enthusiastic adopter of all things implementation science, and I'm really interested in what I would say as both the D, the dissemination research side and the implementation research side. So on the D side, I study direct to consumer marketing strategies at how to best increase consumer awareness of services. I also study how to design light touch scalable interventions that folks can access that make it easier to circumvent the barriers to care. And then on the implementation side, I'm really interested in workforce development issues and how we actually can support a for medically underfunded workforce and in a way that they can actually integrate evidence based practices into their work. And so that ranges the gamut of different strategies and approaches to support the workforce. And I will say as my career has progressed, I've gotten more and more interested in the gap that Dr. Beidas was talking about earlier, which is what I'd call the expertise capacity gap, that there's just an enormous gap between our awareness that these methods are important and the number of boots on the ground that we have that are trained in these approaches. And so I'm really thrilled to be at Feinberg and to have the opportunity to be supporting the development of our own workforce. And I will say that much of the grants I've been writing in recent years and the funding that I have now are center grants where we're really focused on building the capacity of the workforce, creating training and educational materials and tools to help folks that aren't yet doing this research to start to lean in.   

Erin Spain [00:22:09] Well, and you two are both leaders here now at Feinberg, and this is what you're going to be doing is bringing more of this to Feinberg. And I'd like to hear a little bit more from both of you about your visions and your leadership roles. Dr. Becker, you're the director of the new Center for Dissemination and Implementation Science. And Dr. Beidas, you're the chair of the Department of Medical and Social Sciences. So could you briefly both just explain your visions when it comes to implementation science and what we can expect here at Feinberg in the months and years to come?  

Sara Becker, PhD [00:22:40] So the new Center for Dissemination and Implementation Science was formed on August 1st. So really the foundation and the the key focus of our center is helping to support other Feinberg faculty and to coordinate and help elevate and increase the visibility of all the exceptional work that's already happening. That's either squarely within the dissemination and implementation side field or that's really quite close and adjacent to it. And that could be implementation science with a little bit of leaning in. And we are aiming to do that through tripartite goals of scientific leadership. We really believe that in the next five years we can be national, if not international leaders in this space, given the incredible strategic buy in and leadership support that we have here at Feinberg. We also want to be providing intentional support and service to the Feinberg community and beyond to help people to integrate these methods into their work. And then finally, we want to be leaders in training and education and helping to grow the workforce, because as Dr. Beidas and I have been saying, we really have a shortage of talent in this field despite an incredible amount of enthusiasm. So we're very excited to take this forward. And I will say that I accepted this offer in April of 2022, and about a month or so later it was announced that Dr. Beidas was coming as the new chair of MSS. And I think that just increases the enthusiasm and the opportunities as a thought leader in this field, and I'm just so delighted to be able to partner with her in this next chapter here at Feinberg. 

Rinad Beidas, PhD [00:24:06] Thank you. Dr. Becker, I feel exactly the same way. I feel that this is a very special time, a special and exciting time to be at Northwestern Feinberg School of Medicine, to be in a place where and I think it may be one of the only medical schools in the country that has included implementation science as a strategic priority. With the brand new launching of the Center for Dissemination Implementation Science, which Sara is already so ably leading. For me as a new department chair, it's just really wonderful to come in to an environment where there's already so much forward momentum, leadership and vision around advancing an agenda related to implementation science. I think that together with the center and with a department that is very excited about supporting recruitment of more faculty who do work in this space. As well as a lot of existing strengths. I mean, one of the really wonderful things about Northwestern is that there's already so many leaders doing implementation science, and the new center is really going to catalyze and allow for synergy across the departments and all the incredible folks doing this work. Medical social sciences is lucky in its abundance of expertise and excellence and implementation science. And of course there are other departments as well that have this expertise. But I see lots of opportunities for us, especially with NUCATS and the Center for AIDS Research, to really take implementation science to the next level, both in the community, which Northwestern has been traditionally very strong in, as well as in our health system, which I think is a fantastic new opportunity to grow an existing partnerships. And and that's something that I'm really excited about. 

Erin Spain [00:25:53] Well, this may be our first podcast episode about implementation science, but I know it won't be our last, so we'll be excited to have more of your investigators come on the show and talk about individual projects and some of the progress that's been made. We look forward to it. 

Sara Becker, PhD [00:26:08] We do as well. 

Rinad Beidas, PhD [00:26:08] Thanks for having us. This was so much fun. 

Erin Spain [00:26:21] Thanks for listening and be sure to subscribe to this show on Apple Podcasts or wherever you listen to podcasts and rate and reviews. Also, for medical professionals, this episode of Breakthroughs is available for CME Credit. Go to our website Feinberg. Northwestern.edu and search CME.