I have previously written about the meaning of the duty of fidelity: "In ethics, the duty of fidelity also encompasses the concept of faithfulness. To be faithful to a patient means that one will comply with the patient's reasonable requests or expectations. These reasonable requests or expectations can be spoken or unspoken."1 One of these unspoken requests is to be up-to-date. I mention this every time I teach an ethics seminar.
While patients don't come up to any doctor and say, "I don't know about your other patients, but I would prefer that you be current in your knowledge," this is surely an unspoken expectation of all patients. Evidence-based practice is really a method of practicing that is intended to ensure that the best evidence is used to help patients achieve their desired health goals, consistent with their values. Using the best evidence is what patients expect when they desire up-to-date care.
Recently while at an ethics postgraduate lecture, I had quite a few questions from the audience during my presentation on keeping up-to-date. When I finished, a bunch of doctors came up to me and made it clear that they saw the moral imperative to be current, but they just didn't know how to do it. These were moral, conscientious doctors who graduated before colleges started teaching information literacy skills and evidence-based practice. I thought I would answer their questions here, as I do think that maintaining current knowledge is a fundamental duty we owe our patients as doctors – just as I owe my students as a professor.
One of the issues the doctors pointed out is that they know not everything published is high-quality research and thus requires critical appraisal so one can separate the proverbial wheat from the chaff. Doing critical appraisal is a learnable skill and there are both postgraduate seminars on this and textbooks.2-4 Four chiropractic colleges have received grants from the National Institutes of Health to expand evidence-based practice teaching for both students and doctors. These colleges have many excellent resources regarding evidence-based practice for the profession on their respective Web sites.5-9
Until one acquires the skill to critically appraise original (i.e., primary) research, the use of pre-appraised evidence is very helpful. For chiropractic physicians, the starting point should be the Council on Chiropractic Guidelines and Practice Parameters (CCGPP),10 which was created by the Congress of Chiropractic State Associations for this very purpose. The CCGPP has best-practices documents on a variety of conditions we all see in practice – and there are more of these on the way.
Systematic reviews on both treatment and diagnostic methods applicable to the chiropractor's practice can be found in both the Cochrane Collaboration11 and by searching PubMed.12 There is a special feature in PubMed called "Clinical Queries" that specifically will search for systematic reviews, meta-analyses, reviews of clinical trials, evidence-based medicine, consensus development conferences and guidelines.13
There are two final resources to which I want to alert everyone. PubMed will do regular searches for you at no cost, and will e-mail you the citations. To do this, one needs to create a "My NCBI" account; then any search one performs can be saved and made to run at intervals the user determines. For example I get a weekly e-mail with all new citations that include the word chiropractic.
The other free resource is called MDLinx.14 After signing up, one determines general and specific topics of interest (e.g., orthopedics, spine; neurology, pain) and receives daily e-mails with titles of new papers in the topic area. Clicking on the title of the paper takes one to the MDLinx Web site, where there is a summary of the paper and a link to the Web site of the journal in which the study appeared.
The citations from PubMed or MDLinx may be for a paper that is free full text available for download. If the paper isn't free, I recommend setting up an account with your alma mater's library. For a nominal fee, they will get you the full text of the papers -- far more inexpensively than the journal's themselves sell access.
In the 21st century, despite the information overload, there are great resources that make it far easier to fulfill our fidelity duty to keep up-to-date.
- Perle SM. "Treating With Hi-Fi: And Meeting Your Patients' Expectations." Dynamic Chiropractic, March 26, 2009.
- Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 3rd Edition. New York: Elsevier Churchill Livingstone; 2005.
- Haneline MT. Evidence-Based Chiropractic Practice. Sudbury, MA: Jones & Bartlett; 2007.
- Hagino C. How to Appraise Research: A Guide for Chiropractic Students and Practitioners. London: Churchill Livingstone; 2003.
- Evidence-Based Practice Resources: www.uws.edu/Research/Evidence_Based_Practice_Resources.aspx. University of Western States.
- Research Resources: www.nuhs.edu/research/evidence-based-practice/resources/. National University of Health Sciences.
- Foundations of Evidence-Informed Practice (online continuing education): www.nwhealth.edu/conted/distlear/catalog/eip01.html. Northwestern Health Sciences University.
- Foundations of Evidence-Informed Practice: Types of Research (online continuing education): www.nwhealth.edu/conted/distlear/catalog/eip02.html. NHSU.
- Evidence-Based Practice Center: http://w3.palmer.edu/ctl/Docs/Research/ebm_center.htm. Palmer College of Chiropractic, Center for Teaching and Learning.
- Literal Syntheses and Reports from the Council on Chiropractic Guidelines and Practice Parameters: www.ccgpp.org.
- The Cochrane Collaboration: www.cochrane.org.
- PubMed: http://pubmed.gov. U.S. National Library of Medicine, National Institutes of Health.
- PubMed Clinical Queries: www.ncbi.nlm.nih.gov/pubmed/clinical.
- MDLinx: www.mdlinx.com.
Editor's Note: MPA Media, publisher of Dynamic Chiropractic, also has an online resource to keep you abreast of the latest research in an easy-to-understand (and pass on to your patients) format. Visit http://blog.toyourhealth.com/wrblog for quick summaries of the latest research relevant to health and wellness and links to the research abstracts / full studies from which the summaries are derived.
Click here for previous articles by Stephen M. Perle, DC, MS.