J. Michael Menke, MA, DC, PhD
Chiropractors are often skeptical about the value of an evidence-based approach to patient care, and many think evidence-based means "academic." Nevertheless, there is an increasing trend toward provider accountability, and chiropractors must understand how to apply the best available evidence to survive in a highly competitive health care system. Considering the enormous growth of information, practitioners must be able to interpret and apply vast and divergent data to achieve improved patient outcomes. Though research studies can be summarized in review articles, practitioners still need to understand the evidence-based fundamentals before they can appropriately incorporate such information directly into their patient care protocols.
As a profession, chiropractic has thus far failed to widely embrace the evidence-based approach. Meanwhile, other health care professions (e.g., allopathic medicine, physical therapy) have not only embraced this approach, but also have made it a top priority. This is the dominant trend worldwide with health policy-makers and payers. Even massage therapists are taking up the evidence-based approach.
The future is clear: If you want to get paid, you need to understand evidence. I invited Dr. Ron Feise of the Institute of Evidence-Based Chiropractic (IEBC) to provide his views on this timely subject. [Editor's note: The following is not an endorsement of the IEBC or its workshops; it helps illuminate the increasing importance of evidence-based chiropractic within the chiropractic profession and the health care marketplace.]
JM: What is EBP?
RF: Evidence-based practice (EBP) is the application of the best available scientific evidence to health care decisions to increase the probability of favorable patient outcomes. This approach incorporates research findings with practitioner judgment, clinical circumstances and patient preferences.
JM: How do you know evidence when you see it?
RF: As clinicians, we do not need to be trained scientists, but we do need to understand enough to recognize good evidence when we see it. We also need chiropractors to ask pertinent and probing questions when they don't see evidence, and be suspicious when things sound too good to be true. Workshops on evidence-based practice must provide chiropractors with tools to enable them to do these things.
JM: What is the aim of your workshops?
RF: One of the first things we do at our workshops is to measure the level of each doctor's current knowledge. Most doctors do not have a basic understanding of evidence-based methods. This deficit is not limited only to older practitioners who never learned critical appraisal concepts in their chiropractic education. It is equally prevalent among recent graduates. As one of my colleagues, Dr. Jennifer Bolton, has pointed out, our graduates know how to read an X-ray, but not a research paper.
The ultimate [goal] is to improve clinical decision-making, thereby improving the outcomes for all stakeholders: patients, payers, health care providers and society at large. Our workshops are designed to empower doctors by providing a set of skills for assessing and applying health care research. We teach practitioners a way of thinking and provide a practical approach for delivering the best possible outcomes to patients. We do not teach doctors "what" to think about any given treatment, but rather "how" to think by providing them with the skills and tools to appraise new and old treatments and better diagnose.
JM: What types of chiropractors attend the workshops?
RF: We think the doctors attending our workshops are the pioneers in the coming quality-focused paradigm shift in health care. Some attendees are chiropractic leaders, but most are practitioners who see the future of health care. At the end of one recent workshop, a doctor said to me, "If you don't know how to locate and assess research and apply it to your patients, you are a dinosaur among health care practitioners." This comment voices the prevailing sentiment among health care leaders and payers.
The ability to critically evaluate research and select the optimum treatments is an essential skill for successful health care practitioners in this age of accountability and continual quality improvement. It is no secret that insurers are requiring a stricter adherence to scientific protocols. Evidence-based clinicians are the future leaders of the chiropractic profession, because only they will have the expertise to properly apply research and provide more effective and less costly therapies. They will have a competitive advantage.
JM: What are doctors' reactions to EBP training? Is it what they expected?
RF: Most doctors are a little uncomfortable at the beginning of our workshop, because they have so little knowledge about EBP, and many have described the course as intellectually challenging. However, the vast majority of practitioners are surprised that the process of critically appraising research studies is so practical and accessible. Attendees routinely report that they practice differently on Monday morning after attending our workshop. This speaks to the pragmatic, interactive teaching approach we use to ensure that doctors walk away with the skills and confidence needed to immediately implement evidence into their practices.
JM: How can DCs forge evidence-based alliances with medical doctors?
RF: If you want to work with medical professionals, you must know what they like and dislike, what they trust and mistrust. MDs disapprove of chiropractors prescribing extended treatment schedules for all patients, charging "front-end" lump sums for treatment programs, encouraging patient dependency, performing radiographic examination (and re-examination) on all patients, and treating outside a musculoskeletal scope.
Medical practitioners want DCs to provide high-quality correspondence about patients, presentations and scientific literature pertaining to safety and effectiveness, clinical referral guidelines, and their clinics' outcome data. The starting point for all of these communications is an understanding of evidence-based methods. There are no shortcuts.
An orthopedic surgeon recently told me a story that illustrates the' importance of evidence-based knowledge. A DC in his community started sending him letters about the wonders of chiropractic. Not only did the letters look "canned," but one of the letters was also accompanied by a research abstract whose conclusion did not match the data in the text. Needless to say, the surgeon was not impressed with the DC's tactics. It is naive to think that contrived letters or PowerPoint presentations, no matter how well they are crafted, will magically motivate medical doctors to send referrals to your clinic.
JM: How do you handle the issue of chiropractic philosophy in your courses?
RF: Although we ask questions in our classes to stimulate practitioners to examine their clinical decision-making processes, we have not had issues with those who practice based on tradition.
During the course of the workshop, doctors have an opportunity to investigate privately whether their patient management practices hold up in light of research. We do not teach doctors to follow a "one-size-fits-all" patient management strategy. Instead, we offer them a framework for investigation. Ultimately, all practitioners want the same thing - the best for their patient outcomes and to get paid for it.
JM: Can you preserve your iden-tity and beliefs as a DC and still practice EBP?
RF: If you use an EBP approach, it means you're incorporating relevant research into the clinical decision-making process. Sometimes beliefs and science tangle. That is the nature of progress. At one time, we believed that the earth was flat and that flute music would cure gout.
My response to a skeptical DC is that you can preserve your identity, but some of your management practices may need to be replaced with more effective ones. As Claude Bernard said,
"In science, the important thing is to modify and change one's ideas as science advances." As a chiropractor, you can "identify" with providing care that is primarily focused upon delivering manual therapy. But can you cling to a particular treatment if it is found to be less effective than another?
The chiropractic profession can only survive if we place our patients first by effectively applying the best evidence of the day. Is it more important to protect the profession's beliefs and traditions, or to attain the best possible results for our patients?
JM: Thank you.
