Editor's Note: Dr. Lawrence is the sole author of this month's column.
Recently, I traveled all the way to Melbourne, Australia, to present a keynote speech in which I discussed how the developments in technology over the past 30 years have helped to move us to the state we find ourselves in today with regard to evidence-based practice. It was partly a humorous presentation, partly personal and partly educational, and the topic bears some discussion, to be sure.
My Evolution in Technology (and Perhaps Yours as Well)
So, let me return to a young Dana Lawrence, only 12 years old and in middle school. At that age, when I sat in class I used a powerful piece of technology, known as pen and paper, to take notes and keep track of my thoughts. I mean this seriously; paper and pen (or pencil) was and remains powerful in its use.
By the time I was in high school, newer technologies became available, and I took my first course in using a typewriter. It was a manual typewriter, but it changed expectations of how I would use and present information. It was also the only time I ever received a C in a class; coordinated I am not and to this day, I type – rather quickly, I might add – using just four fingers. And in high school, when I was given a research project to complete, as my mother (who was my high-school English literature teacher) might do, I went to the library and maneuvered my way through the card catalogue. Most of you over the age of 30 or so remember card catalogues: stacks of printed cards that gave you information about where to locate a piece of information, usually a book. Today, of course, this is all computerized and few, if any, card catalogues remain.
Off I then went to college, to Michigan State University. In my first year, I learned how to code. Of course, coding in 1971 did not quite look like it does now, where we sit down and write out reams of language in html, Python, SQL or whatever. I wrote in Fortran, meaning I used punch cards and sat in front of a processing station late at night so I could allow my stack of punch cards to run through the machine, and in the end print out the words "Hello, I love you, won't you tell me your name?" The importance here is that this was a precursor to the kind of coding we see today, and it involves a logic that applies to how we find information.
And then I went off to National College of Chiropractic. I was hired right after graduation and began working there, using an IBM electric typewriter. A significant development in technology was the Selectric, which had a window in which a line of text would appear, and which could be edited before it was stored in memory. This meant full pages of documents could be corrected without problem, rather than forcing you to retype entire pages if you discovered one small error. This enhanced the ability to do better work.
So, imagine how exciting it was when computers came along. My father had already purchased a Commodore 64 for my twins, who were all of 4 back then. But I received a piece of a magic, an Apple 2e computer. With its 5.25" floppy disc and 1 MB of RAM, it transformed work. As an editor, I no longer had to lay out pages by hand on sticky board; electronic typesetting systems could to this. Today, I am comfortable using Mac and Windows computers, all sort of programs including those that do statistics, etc.
But the most significant development that helped lead to evidence-based practice was, of course, the Internet. Here is a personal example of how the Net has changed information acquisition. I am a fan of a French progressive rock band called Magma. Over the years, friends around the world would send me copies of material from journals and other places. It took years to amass information about the band. Today, all of those articles are available at the snap of a finger, and I am friends via Facebook with most of the band members.
Evidence-Based Practice in the Age of Technology
For evidence-based practice, acquiring information is a key component of making good clinical decisions. In the past, using what was then called Index Medicus was a chore. You had to go into a library, find the latest copy of the print index (since that is how it came), and peruse the volume, looking for information you wanted. Each volume was hundreds of pages long, and a new one came out weekly.
You would look for a key term, such as leg-length insufficiency, and then you would see lists of authors or titles. You would then have to go into your library to see if it had the journal and issue in which the article appeared. If it did, you then went and copied it. If not, you sent a postcard to the author asking for a copy. A month or two later, you might finally get that copy. The idea of systematic reviews back then was nonexistent.
But the Journal of Manipulative and Physiological Therapeutics, which I edited at the time, was included in Index Medicus. This was a good thing. It meant its papers were published in that huge print publication. But how could one find other information about chiropractic? You really couldn't, despite the best efforts of our librarians to provide access.
When PubMed became the public gateway to medical information, it transformed how we acquire information. Coupled with Google, there is an argument to be made that we no longer need to really remember much of anything, since the information can always be found online. This point was poignantly made in the animated film, "Inside Out," where two "janitors" who are deleting memories to make room for more are questioned about why they wish to delete memories of phone numbers. They respond: "They're all in her phone."
But it is this precise reason that we can practice evidence-based care: because the information we need is now available for us to find. I cannot state strongly enough how critical this is. Information is available today basically at the speed of light. The amount of information is huge and it is growing, and you are in many ways responsible for knowing it. In an evidence-based world, we use an approach known as the "5 A's": ask, acquire, appraise, apply and assess. None of this is possible without access to information via a Web-based portal of some sort. Let's take a quick look at this:
- Ask: We need to ask the correct question. We train students to use the PICO format (Patient / Population, Intervention, Comparison, Outcome) approach, as this fashions a question into something from which you can devise a good search strategy.
- Acquire: This means developing a strong search strategy. Search skills are as important as diagnostic skills, in my opinion, since all good doctors need to know how to find information efficiently and effectively. I remind you, Google is not PubMed, and you should understand how both systems work in order to find information easily.
- Appraise: All information is not the same. Some is good and some is not. You should understand how to determine the quality of the information you are considering using. This is yet another set of skills you can use, and there are online tools available for your use, from instruments to rate the quality of a paper to tools that will help you calculate something such as a likelihood ratio.
- Apply: Well, you found information in order to see if it applies to your patient. Having decided you have meaningful information, you then apply it to the patient.
- Assess: Did it help the patient? If so, great. If not, run the cycle yet again.
All this is possible because our technology has developed to a place where even the public can access and use medical information with ease. As doctors, we can do this well – and should. I know it seems as though this exercise is just that: an exercise that us point-headed academics use. But the power of the Internet is never more clear than when you can locate a piece of information that will directly affect the care you offer a patient.
For the vast majority of the patients you see, you will never need to do this; your training ensures your competence in most matters. But every now and again, you get thrown a loop; some obscure diagnosis or comorbidity affects all your plans and you need more information. This system works, and it works because the tools are there waiting to be used. Use them.
Editor's Note: To learn more about Drs. Lawrence and Goertz, visit their columnist page. The column includes an affiliated blog where chiropractors can post questions for the authors.