Editor's note: This is the second article in a new column focused on evidence-based practice. Future articles will provide evidence-based answers to research-related questions. The column features an affiliated blog where DCs can post questions for the authors.
Evidence-based clinical practice: Does it seem like just one more unavoidable buzz phrase in today's practice environment? Fortunately for us and the patients we serve, it is much more than that. EBCP is an increasingly universally adopted and useful tool that allows clinicians to make more informed health care recommendations to patients. Its foundation, which rests on lifelong learning, enhanced patient care, critical thinking, and the adoption of a universal health care language, is rooted in the belief that the best clinical decision-making occurs when you interlink the current best evidence with clinician experience and patient values. Let's put each of these foundational elements into chiropractic perspective.
1. Lifelong Learning
Or: How many continuing-education credits do I need again this year? The evidence-based approach is an evolution in the practice of health care which arose out of the growing awareness that research outcomes could improve patient care. The increasing accessibility of this knowledge has spurred the growth and general adoption of EBCP.
The speed at which new knowledge is generated and the increased accessibility to this knowledge allow us to integrate the current, best evidence into clinical practice fairly easily. This "direct-to-clinician" approach, driven by technological advances in knowledge dissemination (primarily through the Internet), provides an opportunity to locate relevant information, assess its quality and correctly apply it to an individual patient in real time.
To illustrate how important lifelong learning really is, think about the fact that if you graduated from chiropractic college in early 1985 and learned nothing new about patient care after that, you would not have heard about HIV/AIDS, genetic testing, MRI, or even that rapid intervention during a heart attack can save lives.
2. Enhanced Patient Care
Or: Didn't they teach us everything in chiropractic college? Many of the greatest advances in our knowledge of how to best to care for patients are generated from rigorously performed research studies. The ability to interpret and appraise the quality of these studies drastically reduces the time for knowledge translation from research into practice.
Knowing what evidence does not exist may be just as important as knowing what evidence does exist. The lack of evidence (which should never be confused with evidence against) for a particular intervention, diagnostic procedure or prevention screening procedure should influence our approach to caring for an individual patient.
In many chiropractic offices, it is not uncommon for a patient to show up with a page printed off the Internet. "I am 45 years old; should I have a mammogram?" "Is PSA testing for me?" "What about statins? Hormone replacement therapy?" "Exercise or diet for hypertension?" Your ability to read the literature and understand how to answer these questions is fundamental to your role as a doctor.
Sadly, this is not an easy task. Each new study brings new knowledge; some more generalizable to your patient population. One of our favorite books on how to read the medical literature is called Studying a Study and Testing a Test by Richard Riegelman. Consider picking up a copy. An astute knowledge of the literature facilitates the acceptance of clinical uncertainty, a common experience in everyday practice.
3. Critical Thinking
Or: How do you know what you know? A strong disposition toward critical and self-reflective thinking strengthens clinical reasoning. Evidence-based principles foster the development and refinement of the critical-thinking skills necessary for sound clinical judgment. As a result, providers can become empowered and confident that the decisions they make represent the best available evidence at the time.
It is important to understand the difference between what one believes and what is known. As an example, consider chelation therapy. The Trial to Assess Chelation Therapy (TACT) was a $30 million NIH-funded project designed to determine if chelation therapy is effective in reducing cardiovascular events in patients with coronary artery disease. When JAMA published the positive results from this study last year, many in the cardiology community reacted with shock and disbelief.
Why? Because it is very difficult to let go of strongly held a priori beliefs, even in the face of new evidence.
We would not be a bit surprised if the chiropractic profession faces a similar shock in the coming years – confronting evidence that is inconsistent with our beliefs. When that time comes, we have the opportunity to add to or replace existing knowledge, thus transforming how we care for our patients.
4. Health Care's Universal Language
Or: How do you define subluxation? Evidence-based practice is an approach to health care that guides clinical decision-making across all disciplines and specialties. An evidence-based worldview acts as the universal language uniting all providers in their efforts to provide high-quality health care.
A shared frame of reference facilitates provider communication and collaboration for knowledge sharing in team-based models of health care delivery, such as patient-centered medical homes and accountable care organizations. Further, it ensures a consistency of care that promises only the highest quality standard of care.
The U.S. health care system is rapidly evolving to a more collaborative, multidisciplinary model. As this happens, it is critical that we all speak the same language, using the same terms (and diagnostic codes!) to describe the same things.
To illustrate this point, we invite you to watch a YouTube video from a source of wisdom far greater than ourselves – Star Trek. Just to be clear, we am not advocating that we drop the term subluxation. But we would advocate that we, for example, use the same diagnostic codes as other health care providers. It would make it much easier for researchers to conduct the comparative effectiveness studies required to demonstrate the true relative value of chiropractic care.
When faced with the realities of contemporary clinical practice, an evidence-based mindset leads to the provision of high-quality patient care and subsequently, optimal outcomes. While there is no doubt that some time and effort are required to obtain the necessary skills for the application of evidence-based clinical care, the benefits of adopting this approach are well-worth the effort.
For additional information about Drs. Lawrence and Goertz including a link to their columnist page, visit their blog.
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
