Hard Facts

It's been a long time since I gave a book report, but I just can't resist telling you about the latest volume I've digested. The book is Hard Facts, and it has a few subtitles: Dangerous Half-Truths and Total Nonsense: Profiting from Evidence-Based Management.¹ The book is authored by Stanford University professors Jeffrey Pfeffer and Robert I. Sutton. Here's the Table of Contents:

What especially caught my attention was the first chapter, "Why Every Company Needs Evidence-Based Management." In a subsection labeled, "Evidence-Based Medicine: A Model for Evidence-Based Management" (pp. 13-14) the authors acknowledge David Sackett, MD, MPH, as the founder of the modern evidence-based medicine movement. Dr. Sackett and his team at McMaster University in Canada screen out 98 percent of published articles to find the best 2 percent of information sources. I was struck by the similarity of their task to the work of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP). Although the CCGPP "best practices" guidelines for the care of low back pain patients have created an uproar in some corners of the profession, I suspect their task is essential for our profession as we move into the 21^st century and the age of accountability in health care.

Pfeffer and Sutton review Sackett's explanations for why doctors don't use the best available evidence to generate diagnoses and treatment options for their patients. Pfeffer and Sutton's concern ultimately is why business managers often fail to use the best available data, but the parallel to the practitioner's situation is remarkably similar: They trust their clinical experience more than the latest research data. Hard Facts also enumerates Sackett's additional explanations for overlooking good information: There's too much to try to absorb and most of us haven't been trained to distinguish between strong vs. weak evidence. As well, clinicians are inundated by vendors who tout the supposed benefits of their products, but neglect to review the risks and weaknesses. (Think about the Merck Corporation and its marketing of Vioxx.)

The authors of Hard Facts note that physicians trained in evidence-based techniques are better informed than those not so trained, even 15 years after graduation. I think that has tremendous implications for evidence-based chiropractic. One of the greatest obstacles to the scientific practice of chiropractic is our allegiance to traditional clinical concepts that have little or no evidence to substantiate them. The antidote, I believe, is our willingness to learn how to track and evaluate the best information as it emerges in the clinical science literature. Chiropractors certainly are not alone in our traditional reliance upon clinical judgment, but we are exceptional in our rigid adherence to untested clinical theories and methods.

Chapter two quotes the CEO of a large company: "If the decision is going to be made by the facts, [then] anyone's facts, as long as they are relevant, are equal. If the decision is going to be made on the basis of people's opinions, then mine counts a lot more." Does this sound like many of our political organizations in chiropractic or our tradition of charismatic leaders who offer the one true theory, technique or philosophy of chiropractic? Are we just sheep waiting to be led?

When I graduated from chiropractic college 40 years ago, there was little, if any, hard data concerning the risks and benefits of spinal manipulation for low back pain patients. Twenty years ago, we in chiropractic were just beginning to get involved in the burgeoning field of clinical outcomes research in the manual healing arts.^2,3 Today, we can take some pride in the accomplishments and continuing investigations of the research community in chiropractic.⁴ Our teams of investigators have taken us well beyond some of our earlier "half truths and total nonsense." They are asking hard questions, digging up hard answers and reporting their findings honestly, whether they buttress or refute many of our traditional and cherished chiropractic beliefs. Their bottom line, like that of all clinicians, is what's best for the patient.

Good research, however, is only the first step. Chiropractic has begun to mature - perhaps in spite of itself - because of those pointy-headed, ivory tower dwellers determined to do real science. Now it's up to us, the real, live clinicians in the field, to learn how to make the most of what our scientific community is uncovering: what works best for which patients with which problems, irrespective of our preconceived notions. Yes, we will need help to learn how to understand and implement what our researchers are discovering. However, the simple reality of our situation is that we must take the initiative to embrace evidence-based chiropractic. Pfeffer and Sutton's book underscore a notion that's stuck with me for some time; it's as true as clinical practice as it is in business: If we can't measure it, we can't manage it. The choice (and the responsibility) is ours.

References

1. Pfeffer J, Sutton RI. Hard Facts: Dangerous Half-Truths and Total Nonsense. Boston: Harvard Business School Press, 2006.
2. Kaminski M, Boal R, Gillette R, et al. A model for the evaluation of chiropractic methods. Journal of Manipulative & Physiological Therapeutics, 1987;10(2):61-4.
3. Waagen G, Haldeman S, Cook G, et al. Short-term trial of chiropractic adjustments for the relief of chronic low back pain. Manual Medicine, 1986;2(3):63-7.
4. Bronfort, G, et al. Spine, 2004;4(3):335-6.