On “Evidence-based” Practice / Medicine

These 2 tweets resonated with me:

I’ve tweeted my thoughts on Evidence-Based Practice, but it might be worthwhile to organize my thoughts on this topic in a blog post – one that will likely evolve over time.

The way I see it we need research (evidence) for a few basic reasons, but one in particular stands out to me: to improve our clinical practice in terms of efficiency, application, and outcomes. Admittedly, there are different way to get on this path of improvement; research-based evidence is one of them. Many passionate individuals have taken this path and espoused the triumphs of an Evidence-Based approach. The most common question (implied or blatant) in online discussions is “Where is the evidence?”, or some version of it: “Does the research support that?”, “Can you back that with data?”, etc.

All this reliance on data and research makes me wonder how strong of a panacea research data might represent. How pure is the science in research? How unbiased are these published “peer-reviewed” articles? What about the unpublished ones? Why were they turned down?

What about when the “facts” change? Just consider the many fluctuations in nutritional research over the last 30-40 years. Dietary recommendations seemed to change haphazardly. Here’s one on when you should start introducing your children to peanuts:

Is it any wonder that the public is losing trust in scientists and scientific journals? Can such uncertainty, wavering, and poor research infiltrate medicine?

Of course it can; just look here and here. I started to wonder when this would bleed into the world of physical therapy. The more I thought about it, the more I realized that it was already on the minds of some clinicians. Other than tweeting their opinions, some of them have even written up their thoughts in blog posts. Here are some interesting reads:

Metacognition, Critical Thinking, and Science Based Practice by @Dr_Ridge_PT. This is a solid read with links to relevant articles by others.

Where’s the Evidence? by @The_OMPT is a succinct read that echoes some of my sentiments.

And finally, The Tyranny of Evidence-Based Medicine by @DrGregBrown is another very worthwhile read.

All this research data and journaled evidence can get very overwhelming. The Cochrane Collaboration does a nice job of filtering through the flood of journaled publications. Their work is important and very necessary, but there might be something even more important and necessary. I’m not sure if I should call this critical thinking or clinical reasoning, but it boils down to the skill of assessing the outcomes of your interventions. Can it be done? Some say “no”. I say “yes”.

Let me clarify. I’m not talking about an understanding of the biopsychosocial process behind the outcomes, but the Clinical Process that yields the Outcome. (Look here for more on my thoughts on Process & Outcomes) This approach is blatantly Practical by applying the concept of phenomenology leaving the “how” to researchers and academics. According to Taleb from his fantastic book, Antifragile,

Phenomenology is the observation of an empirical regularity without a visible theory for it.

This rhymes with a very practical concept of mine: If treatment X consistently precipitates outcome X for condition X, then you might be onto something. This side-steps the need for biological, psychological, or any other explanation and leaves you with a straight-forward practitioner’s application or approach to a particular presentation.

Dr. Greg Brown echoes some of my sentiments in the closing paragraph of his fantastic post:

The bottom line is that there are two sorts of Medicine — the sort which works and that which doesn’t. Outcomes are the final arbiter. The promise of all this is that the practice of Medicine can once again become what it has always been — a person seeking help, and the practitioner providing a perspective. Without the tyranny of EBM, there is no longer a third entity in the room. It is no longer good enough for “the evidence says” to be the end of the conversation. Its premise is false, its promises illusory, its autocratic arrogance no longer tenable.

EBM is dead, only most of us don’t know it yet. Long live outcome-based medicine.

By no means am I discarding the value and worth of research. (Although, I must admit the EBP folk are starting to remind me of fundamentalists. Their certainty is more fragile than they may realize. Then again, I could be wrong.) It is a valuable machine that drives much needed efficiency in the profession. There is also a link between research and re-imbursement that you should consider. Dr. Sandy Hilton, DPT, MS did a fantastic job of explaining some of this for us:

Physical therapy research is an interest of yours. Tell us about the connection between research and insurance reimbursement. I think this is something most PTs (including myself) should know more about.

That’s a great question.  Specifically for pelvic health (incontinence, post-prostatectomy, pregnancy, sexual dysfunction, transgender work) there is a perceived push from the insurance companies to deny treatment as not medically necessary.  We need more quality research regarding the benefit of PT intervention to decrease the number of visits needed to reach functional independence.  We also need research showing that the quality of life and functional outcomes lead to less payments by the insurance company.  (of course, if studies are conducted and my theory is false – and PT doesn’t really make a difference, we must accept that and change!)

Right now there are insurance companies denying PT visits for bowel dysfunctions, bladder dysfunctions and sexual dysfunctions due to their interpretation that Physical Therapy is not needed, or that there is insufficient proof that intervention will alter outcome.  I think more participation in outcome studies such as available through FOTO will help shape the future of insurance reimbursement.  I care about this for the profession as a whole, even through my clinic is out of network for all but Medicare and Tricare.

Going back to my original thesis, evidence should enhance NOT tyrannize your practice. I believe we have reached (or are nearing an apex) of data deluge that necessitates the ability to filter through numbers, graphs, conclusions, and implications to distill real-world applicable practicality. Many Randomly Controlled Trials do not reflect the world we live in simply due to the fact that our world isn’t a Randomly Controlled Trial, and definitely isn’t Double Blind. Context and psychology play a major role in everyday situations, and (in my opinion) can over-ride any RCT conclusion. Subjective Perception is Powerful.

The ultimate filter (clinically) is our skill in assessing the outcomes of our interventions. Here are 3 links to help you along the way: one, two, and three. The third link is my favorite by a long shot!

Also, I encourage you to read the entire Twitter-thread sparked by Marc Andreessen. Equally worthwhile (and more relevant) read these 3 threads sparked by @NicoleStoutPT: onetwo, and three. (Again, the third link is the best!)

Could I be a bit off? Without a doubt. Mostly wrong? Absolutely. Completely wrong? Definitely. Either way, I want to hear from you. This way (maybe) I’ll be less wrong. Also, I plan on evolving this article if anyone convinces me of anything worth changing. I’ll leave old material in strikethrough font so that any change in my thinking can be followed.

I am @Cinema_Air.