Does EBP and its pursuit have any drawbacks?

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In my mind, unquestionably. How much 'quality' research exists? And if your answer is "not much", then how can a musculo-skeletal clinician adequately treat his/her patient within these terms of reference?


I (semi) understand the necessity of its pursuit. It is the only avenue for a profession to become credible in the eyes of the patient and the health economist.


Since the outstanding research of Jull and Richardson (QLD), the physiotherapy profession across the board, dogmatically treat every lower-back condition with transversus abdominus and core strengthening. Unfortunately, students of EBP-driven universities/associations have this one tool in their knapsack. If this is the only proven gold-standard treatment for back pain, then suddenly back pain has one cause. If back pain has one treatment and one cause, then why bother assessing it in the first place? Why not just close our mind and treat it recipe-style.


IMO, EBP is giving the musculo-skeletal students of today the "recipe" for success. It is stopping them from thinking mechanically and using basic physical concepts.

Seven years ago, I was prescribing everted wedges for medial compression pathology in the knee. Back then I was unethically "experimenting". After Hinman, Payne and Co. release their current research on it soon, I will be able to stop apologising to the guinea pigs of the past.

What should I do as a clinician, when a patient comes to me after years of EBP from another clincian, informing that the condition has long plateaued. Should I put this patient on the same ride? Or can I dare think laterally, mechanically, and do something 'different' that makes sense.?

Results-based-practice should be elevated to the same prestige as EBP. Results based practice puts the onus on the clinician to get subjective and objective results or move the patient on (intra and inter professionally). But some egos may be tarnished, and some hip-pockets hit; so I won't hold my breath.

 

Ron - good points. I will respond later as in the Rockies for some R & R between conferences .... BUT, shouldn't you be studying for exams????

 

Atlas,

There's an excellent series of papers in the British Medical Journal that is essential reading for anyone who wants to learn about EBM/EBP. Here's a selection (all free full-text access):

Evidence based medicine: what it is and what it isn't

Using research findings in clinical practice

Barriers and bridges to evidence based clinical practice

Physicians' and patients' choices in evidence based practice

With due respect, I think you've misunderstood the concept of EBP. When you cut away all the jargon, essentially all EBP means is using research evidence to assist in clinical decision making (not a particularly radical idea, really). It doesn't mean adopting a recipe approach, or treating everyone the same way (as in your back pain example).

Perhaps the best description of EBM is by Sackett:

"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice...Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough"

Regards,

Hylton

 

While I am all for research evidence to support what I do for my patients on a daily basis, I am not supportive of restricting logical and mechanically based treatments that are clinically effective but lacking research evidence, all for the cause of evidence based medicine (EBM). I really think restricting treatments to only those that have research behind them is not always in the patient's best interests.

I believe that it is only the very near-sighted clinician or the insurance company or the government health plan that is interested in limiting the treatment of individuals with musculoskeletal pain to those treatments that have research evidence behind them. One of the reasons evidence-based research is so popular now is probably that this is one way for insurers and government health to have what they consider a valid excuse to deny effective (what they call experimental ) treatments so that they can save money on health care for the members they are supposedly caring for. I really hope that no one actually believes that these insurers or government agencies care that their decisions to restrict care to only "evidence based treatments" is based solely on wanting to help patients?? Come on now, let's not be so naive!

For example, since there is no research evidence that the medial heel skive technique is effective at treating patients with posterior tibial dysfunction, then this "experimental" technique, that is now 15 years old, would not have been used by the "evidence based only clinician". I think that the hundreds of patients I have cured from PT tendon pain with this technique are very happy that I didn't wait years for definitive research to finally claim that the medial heel skive orthoses is effective to treat patients with this pathology. I am sure that these patients are very happy that I have used mechanical intuition and modelling techniques to come up with mechanical therapies for many foot and lower extremity pathologies that have not been studied or even had clinical names applied to them. Do you really think that patients care if their treatment is "evidence based" as long as it gets them better and relieves their pain?!!

I didn't get into this profession to practice evidence based medicine. I got into this profession to make patients better and whatever it takes to make them better is exactly what I will give to my patients, regardless of whether it has research evidence to back it up, or not. I will probably be retired or dead before the research catches up to the many techniques that I use on a daily basis to heal patients' foot and lower extremity injuries. I am not willing to allow my patients to suffer needlessly waiting for researchers to catch up with the logical mechanical thought processes that go into the treatment decisions that I make on a daily basis. I really could care less if someone thinks that I am an "evidence based clinician". However, I do care greatly that patients think that I am an "effective clinician".

 

"Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough""

I totally agree. Unfortunately, there are many well-intended practitioners that are just using one (research proven) strategy, over years without any clinical change in their patients' condition.

Gardner's rule (leg problems = rearfoot aggressiveness; foot problems = mid/forefoot aggressiveness) is a perfect example. It makes complete and utter mechanical sense, yet is scorned in some parts because no pristine research supports it.






Great post Kevin.

I would rather my musculo-skeletal clinician spending one day with you understanding (not remembering) musculo-skeletally-relevant-physics, rather than them read a library full of research.



The other thing is when I graduated in 1995, I was willing to pay $$$$ and go to a conference to become a better clinician next Monday. Instead, what I got for my money was 90% statistics, and why the research was inadequate; and by the next Monday, I was the same ineffective, inefficient practitioner. (That is why CP's Boot Camp was pretty good: it included the evidence/research, but it also made me a better clinician the next Monday.)

 

Great thread Atlas.

Here are some problems with EBP that I see:

1) It becomes a weapon of insurance companies to deny treatments as Kevin eloquently stated. They will yank reinbursment based on a crappy study much quicker than begin paying for something well proven.

2) It removes the human element of evaluation and treatment. Many of the conditions we treat, although physical in nature, also involve behavioral issues. These complex issues are not captured in most research designs- with the exception of BF Skinners work with rats.

3) The more you move towards the science of medicine, the further you move away from the art of medicine. Much of podiatry is an art.

4) It does not include issues of common sense. We all know that applying direct pressure on active bleeding prevents further blood loss and aids clotting. There are no controlled studies proving this. What would an EBP clinician do- apply topical thrombin over direct pressure in a trauma patient with massive bleeding because the former has been proven to work ???

 

I always enjoy reading "clinicians" responses to discussion about evidence based practice --- many comments are related to a misuderstanding of exactly what it is (Hylton cleared that up) and other responses are about bagging it and coming up with reasons not to use it. .... the paradox is that we do not have a choice as was alluded to above re 3rd party funders. We need to get with the program or face an even more difficult future.

I will repost Sackets quote from Hyltons message above:

EBP has ever been about usurping the 'art' of medicine (or podiatry) and not sure people got that misunderstanding from.

(You want to see what I see out my hotel window this AM--- snow covered mountains in the Canadian Rockies and beautiful sunshine ....and I have to get some powerpoints ready and respond to a clinical education review and ....)

 

Craig: Hope you are enjoying the Canadian Rockies...got to be better than the rain and overcast in Vancouver for PFOLA.

Since I consider myself one of those "clinicians", I feel that we are being denied effective treatment protocols to our patients who are in pain by insurance companies who claim that these treatments are not "evidence-based" or are "experimental". This creates a situation where I can not practice what you and Hylton said that Sackett claimed is evidence based medicine:

"The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

The problem is, Craig, that the insurance companies are not allowing me to integrate my "individual clinical expertise" since they are saying that I must use, only, external clinical evidence from systematic research. So maybe, in theory, EBP is wonderful and glorious as a treatment model (much like communism is a great idea, in theory?), but for us in the "clinical trenches", fighting every day for the well-being of our patients, it sometimes makes me wish for the good old days when the insurance companies just listened to my years and training as a podiatric physician as what I said needed to be done for the well-being of the patient, and then approved the treatment.

My previous comments still stand. I think we, as a profession, should all strive for EBP since I think, in theory, it will be a good thing for all of us. However, the greater powers that approve and deny treatments for our patients are taking great advantage of this treatment model by not allowing us "clinicians" to use "individual clinical expertise" for the benefit of our patient, thereby prolonging pain and possibly causing harm to our patients.

 

Let it bleed until a decent paper (with a large sample size, minimal error, and a low p-value) comes hot off the press.

 

"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice...Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough"




The more I read Sackett's quote, the more I like it, and the more I feel practitioners/universities aren't doing "enough". I would guess that most university musculo-skeletal institutions are going the whole hog with EBP. It would be refreshing, to see one old wise (wo)man employed strolling amongst students and offering her/his deep clinical experience. "The research may say that, but I have found across the board that.....".


I would not recommend for instance, any prospective associate lecturer at his/her job interview to dare say, "I think I can compliment this place. I think I can add a clinically relevant addition to the EBP that you emphasise. I am not necessarily an EB-practitioner, but I think I can help students understand when EBP does not seem to be improving their patient, and what other common-sense mechanical alternatives that can be applied". I am certain that this prospective university employee would not get the job...which is a shame IMO.


As for the current EB-practitioner...
I think the typical EB-practioner is pretty comfortable reviewing his/her patient time after time, knowing that they are applying "current best evidence", despite the patient under them not progressing one iota. Instead, we tend to blame "psychological issues", "non-compliance" and "financial motivation" for a lack of progress; which is ironic in that our psychology training is virtually nil.

I am of the opinion that the current EB-practitioner (of a non-progressive patient condition) is ignoring Sackett's ideal principle and not drawing on the clinical experience of other experienced professionals (intra and inter) in the hope that they could find the missing piece of the jigsaw. My ideal principle of Results-based-practice deals with this, because the ultimate judgement is on whether the patient is improving. And that is what the face-less bean-counting health economist should be concerned with.

 

Four points:

1. EBM may be used as a "weapon" for insurance companies to deny coverage of some treatments, but surely that's a problem with the way healthcare is funded, rather than a problem with EBM?

2. No-one seems to be considering the possibility that EBM might actually make you a better clinician. If there's strong evidence that a particular treatment is more effective than the one you're currently using, surely you (and your patient) would be better off using the more effective treatment?

3. Some clinicians appear to have an uncomfortable relationship with clinical research. If it supports what they're doing, it's great research, if it questions what they do, then it gets criticised. As podiatrists we are also quite happy to criticise some complementary/alternative medicine approaches due to the lack of evidence to support them, but then get all spiky when the spotlight is turned back on us. We can't have it both ways.

4. Academic staff seem to cop the brunt of this sort of angst on a regular basis. The fact is that most clinical researchers were (or still are) clinicians and are actually trying to help the profession.

 

Good point, Hylton.

Communism seems like an ideal type of government in theory. However, in practice, we all know how communism works....not very good for many of the people of the country. We say that we may "dislike" communism because of the failed examples of communist countries that we are aware of.

In much the same way, I agree that EBM is a great idea, in theory. However, in practice, insurance companies are using this great theoretical ideal of treatment as a way to deny many treatments that reasonable clinicians would normally use in their practice for the benefit of their patients.

So maybe you are right, Hylton. I don't dislike EBM, I just don't like how the bean counters of the insurance industry are hiding behind the EBM banner as their latest method by which to withhold treatment from our patients that are in dire need of effective therapeutic modalities that would allow them to better heal from their musculoskeletal injuries.

 

Yo! Atlas (aha! Craig has given it away, I know who you are, and remember under the new Australian laws sedition is treason and indictable. What you speak of is academically seditious.)

Actually, from the teaching point of view, you bring to the forefront some really interesting issues.

As a profession our EBM body of knowledge is embryonic. As for empirical knowledge, we are rich beyond the dreams of avarice. So, what do we offer to our students who are in a fragile state of cognitive and clinical skill development?

They crave the certainty of "Univeristy tests have proven.....", as it gives some scaffolding to their construction of understanding. But, we genuinely cannot afford to give them that certainty, as it is only through uncertainty and challenge that we can question and develop. (Vygotsky called this the 'zone of proximal development', but I think he probably didn't have a sex-life and needed to invent bully-words to compensate).

If we offer the divresity of opinion that comes from clinical experience (and you only have to live through a few clinics to know there is nothing that pisses you off quicker than to have different clinicians telling you that X's opinion is wrong and theirs is right), then the students become anxious and confused.

I don't think there is an easy answer. But it is a discussion worth having. If clinical undergraduate education is to respond to the evolution of our profession, we need to think about the nexus of research and clinical practice with a more open and curious eye.

cheers,

Felicity

PS. Go and study for your exam tomorrow

PPS. Craig, I love you deeply, but tell me about the views one more time and I will have to hurt you. In Melbourne it is raining, and the exam piles are not getting any smaller. I hate piles.

 

​

This is the view I have to suffer through looking out the room window ....while I am stuck inside here all day working .... and don't forget the exam pile in my office is building up for when I get back and then there is the Boot Camp.

Back on-topic
I don't disagree with any of the sentiments about the problems with EBP .... except its now, likes taxes and death, a fact of life we have to get used to it and make the most of it.

I do like Hylton's comment:

It is interesting looking at peoples response to research results that I get that they do not like .... do you think I deiberatly set out to proove what I found? (I commented on a reviewers reponse to our LLD research here).

 

To paint this as some battle between clinicians and academics is partially wrong. In fact, return to my first post on this thread, and some of my concern is aimed at "clinicians" who have swollowed EBP bait; hook, line, sinker, rod and arm. As I said, there are physiotherapists out there continuing to prescribe core strengthening 2-3 times a week, despite no progress for years. Worse still, no radiology, no second-opinion seeking, no referrals. And I am sure, but not certain, that this applies in all musculo-skeletal fields.



Academics? Clinicians? Whoever? It is rare to find a musculo-skeletal teacher/practitioner who takes into account all of Sackett's recommendations.

 

I am new to this so may be a bit behind you all but what about Value based practice - what the patient/client wants and Political based practice - what the purse holders want?

 

ruth cocks

having recently discovered this site I am interested to see the trends of thoughts and dcommon misunderstandindgs-that EBP prevents choice of management , rather than prompting the therapaist to evaluate , the needs of the individuals problem and therapies which may help.
At least EBP and the demand fir it by various parties , patients most of all ,will force practioners to improve the quality of their care for patients.By this I mean the type of practioner who was taught something in training and sees no reason to change or who does not regualarly actively update and implement changes in treatment modalities despite attending statutory traing for reregistration .
It is a very important tool to maintain and increase the credibility of professions and therapists despite the efforts of those I metioned above,and should be treated as such by the more enlightened

 

If you'll take a look at the current pedagogy of any subject taught today, be it history, economics, mathematics, or even podiatry, the overwhelming trend is in the encouragement of critical thinking skills. EBP is nothing but critical thinking-- taking the best available information (from experience, from clinical studies, or from something written on the bathroom wall), deciding which pieces of it to use and which to throw away, and synthesizing the solution to a complex problem. The only think new about it is it now has a fancy acronym. The best clinicians have always taken the best available information and used it. Somewhere along the way, someone who stood to gain a lot of money from doing so, decided they could change critical thinking into EBP and begin telling clinicians that they can only use certain bits of information-- in effect telling them how they should be practicing medicine. Insurance companies have been getting rich by telling doctors how they should practice medicine for years. This is just one more way to line the insurance companies' pockets.

 

You're right. It should all be about critical thinking, clinical reasoning and common-sense. But it isn't. As I said before, most of us across a number of professions, academics and clinicians alike, have swollowed EBP hook, line, sinker, rod and arm. I can see its necessity, but in this early stage of quality research, EBP at best gives you a first line treatment approach in a few textbook conditions.