How to Build an Evidence-Based Practice

What is all the fuss about evidence-based practice? Is this something new? Is it a plot by the payers to deny payment to physicians? Is it of benefit to the patients? Is it of benefit to the doctors? Is it beneficial to the health care system? How about its benefits to practice?

These are all questions that are being asked daily using the increasingly popular catch phrase of "evidence-based" care. It is interesting to note that the AMA utilized the tactic of "lack of evidence" to discredit the chiropractic profession and now is having controversy within its own ranks in regard to implementing evidence into the clinical practice of its own constituents. Over the past few years, I have seen and participated in the same debate within the chiropractic profession. How should our profession deal with this new paradigm? Better yet, how should our clinicians deal with this new paradigm?

The debate in our profession seems to pit the academicians and researchers against the clinicians. The clinician is most interested in how the evidence will affect their patients. However, the clinician is the least adept at understanding the evidence. The academicians and researchers are adept at understanding the data, but do not always deal with its clinical applications on a daily basis. The future of health care and the growth of the chiropractic profession will be contingent upon the merging of these groups, and the evidence-based practice will provide the ability of the chiropractic practitioner to integrate into the health care system.

As a clinician, a past regulator and a consultant who has reviewed records from many offices, I have had the opportunity to obtain a bird's-eye view of our profession and how the clinicians are embracing these concepts (or not). After encouragement from a few colleagues, I have decided to share some of my personal observations and implementation strategies. Some practitioners have successfully utilized the transition to evidence-based care to not only improve patient care, but also to build their practice. Let's review some of the successful strategies in merging quality, evidence-based care with practice management.

The first stage for the clinician is to obtain the knowledge. Most of the practicing clinicians today graduated at a time when there was insufficient emphasis on evidence-based care. Doctors were trained solely as clinicians. Graduates would obtain their degree, along with some debt, and were most interested in treating patients and improving their financial situation. There was very little training in reading the research, critically appraising it or even understanding the different levels of research. Only a select few pursued knowledge in this area, often on their own time, unless they were interested enough to pursue another degree at another institution that would train them as researchers.

Today, our profession owes a lot to these select few. It was these individuals who were able to lead the way into the AHCPR, interdisciplinary research meetings and symposiums, provide data for implementation of chiropractic care into the Department of Defense and Department of Veteran Affairs, and open many other doors to increase access to chiropractic care. The question remains, what can you do as an individual practitioner to enhance the profession and your practice? If you are truly motivated, you can be successful in accomplishing both. In order to obtain the knowledge, there are many seminars being offered now within our profession and by (of all people) the physical therapy profession and the medical profession. There is also an Evidence-Based Practice Boot Camp being planned by the CCGPP. Locally, I found it beneficial to call up the local university and discuss the situation with the statistics department. Since I was only in search of knowledge and needed no credit, the professor of the graduate biostatistics class was pleased to allow me to audit the class.

This would not have been very exciting to me a few years ago. However, I was tired of reading literature and not understanding the statistics sufficiently to evaluate the paper for use with my patients. I also would get lost in discussions with researchers or with the local medical doctors regarding the latest research and the appropriate care. Sitting through a biostatistics class now became enlightening. Each new topic explained something I had read and it had immediate applications. This is certainly not for every practitioner, but it certainly filled in the gaps for me. Now, when patients would ask for my opinion about treatments offered by their medical doctor, I could answer them in an unbiased fashion. I was no longer relating my personal opinions, which they could either accept or reject on the basis of how much they liked or respected me. Instead, I could call up the statistics from the research to substantiate my opinion or to give them the information to make an unbiased decision. Now, when I would see a paper that made a conclusion based on P>.05, I knew that there was an increased likelihood to come from the general population (chance) and not be statistically significant.

It was really amazing how much medical care was being recommended to patients based on the philosophical, financial or dogma views of their medical doctor. By relating the information in this matter, without any bias of a difference in philosophy of health care, the chiropractic physician is able to build credibility. It is the medical doctor that now begins to lose credibility and confidence of their patients. Soon enough, the patients are coming in with questions from their friends. This inevitably leads to their friends coming in for consults. Wow, that audited (free) biostatistics course certainly was more productive than a large Yellow Pages advertisement! Now, patients are going back to their MDs with information from the local DC that is not unscientific opinionated jargon, but valuable information that can be discussed with a fellow colleague on an academic level. This is followed up by respectful feedback from the MD to the patient and referrals of patients. Wow, the biostatistics are really getting exciting now!

Additional knowledge and experience in conducting literature searches is essential. One can easily go through a tutorial on PubMed or MANTIS. To be adept at this takes repetitive searches and some practice, in order to obtain the experience. Once it is obtained, it can be done quickly in your office for your patient inquiries. One patient came into my office with a typical story. They were suffering acute, mechanical, low back pain without any radiating pain. But their primary care physician was referring them to a physiatrist for epidural steroidal injections. They didn't know who to listen to or what to do. They asked me for my opinion. My biased opinion was that the particular physiatrist felt chiropractors were their main competition, and they never spoke well of them and would steer patients away.

However, it would be improper to get involved in a nonsense philosophical or economic debate, with the patient stuck in the middle. Thus, this was not even discussed with the patient. The patient just wanted the facts to make an educated decision. I suggested we look up the evidence regarding this procedure being a primary intervention. Well, we do not have to go far to find that AHCPR guideline #14 from the NIH (great credentials) states, "There is no evidence to support the use of invasive epidural injections of steroids as a treatment for low back pain without radiculopathy," with a strength of evidence graded at "D." This indicates that there is very little research available, so it is left to the expert opinion of the limited research that is available.

A quick PubMed search reveals a paper in the journal Pain that concurs with NIH that "beneficial effects are of short duration." This was all done in the office, while the patient was still present. A systematic review of the literature showed that 50 percent of the studies revealed no change in the condition. I was able to give them the evidence, as related by the expert third parties vs. my own biased opinion. This left the impression of an uninformed referral by the PCP and biased decisions by the physiatrist. Whom do you think the patient subsequently trusted with their health? When there was a response to care, they not only referred patients, but also warned them not to always accept as fact the recommendations of the PCP or physiatrist. It should be noted that their statements were derived by means of their own experience vs. improper professionalism by the DC. Well, this certainly built more credibility than a newspaper advertisement, and at less expense.

This is only the tip of the iceberg for education. Literature searches and statistics are, of course, a very small part of our practice. One also must understand the evidence and how to find the evidence to answer the clinical questions. Then, you must decide if the evidence is applicable to the individual patient, integrate the information with your clinical judgment, and apply it with the patient's values and desires in mind. Making the transition does involve a learning curve. Anything good usually does. In the end, it can be well worth the effort.

In follow-up articles, I will expand on the above, including other areas of knowledge to pursue. I also will review other methods employed through evidence-based practice which allow the practitioner to increase their credibility, improve care, improve referrals, decrease overhead expenses, lower practice stress, respond to third-party-payer restriction, expand their practice, establish interdisciplinary care and open up opportunities for interdisciplinary practice.