Embracing Evidence-Based Chiropractic

t has become increasingly apparent that the value and efficacy of health care professionals will continue to be measured by the degree to which they adhere to evidence-based practices.¹ Government, third-party payers, stakeholders and patients expect treatment or interventions to be based on evidence that supports effectiveness in achieving desired outcomes with minimal negative consequences.

In 1938, John Paul introduced a new basic science called clinical epidemiology to the emerging field of preventative medicine.² Over the ensuing decades, very detailed and specialized knowledge has accumulated in the form of scientific research. It is stored in massive databases, selectively retrieved and subjected to critical appraisal. Carole Estabrooks, et al., from the University of Alberta in Edmonton, chronicled six decades of knowledge transfer and its impact on scientific discovery, technological innovation, and decision analysis, including health care policy and accountability.³ The translation and utilization of this select knowledge has provided the opportunity to use evidence in decision-making as well as to better inform health care professionals, including chiropractors.

The Journal of the American Medical Association published the seminal monograph on this topic in 1992: "Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine."⁴ This was followed in 1993 by the Cochrane Collaboration, so-named as an homage to the epidemiologist Archie Cochrane's life work on systematic reviews of the literature. Access is available free to all Canadians until the end of 2009 (www.thecochranelibrary.com).

In 1996, Sackett, et al.,⁵ defined evidence-based medicine as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." This definition has been broadly accepted and widely cited in the peer-reviewed literature. However, what has often been overlooked is the authors' very next line, which states: "The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

Unfortunately, most health care providers fail to keep pace with the current literature and miss the opportunity to implement key clinical research findings that should influence their practice behaviour in a positive and progressive direction. Many doctors of chiropractic have published excellent research in the best peer-reviewed journals that have never been read or even retrieved by the very clinicians who would benefit most from this information.

The notion that "evidence is information and information is data that has meaning" assumes relevance in the current debate concerning "evidence-influenced" and "evidence-informed" consent to treatment. In the highly litigious and regulated world of patient safety, there are two principal paradigms that influence modern patient care and accountability: patient-centered and evidence-based. In the patient-centered model, the perspective is humanistic and biopsychosocial to encourage and facilitate a patient's disclosure of worries, questions about side effects and an uncertain future. The focus of the discussion between doctor and patient is more on the patient's perspectives. The intent is to arrive at a negotiated decision aligned with the patient's needs and preferences. The reality is that most patients are not equipped or are simply unable to make good decisions about their care, and 77 percent of them prefer that their physician make the decision for them.⁶

But is it valid to assume that training and specialized expertise provide enough authority to practice these skills on unsuspecting humans? David Sackett addressed this question with regard to the business of preventative health care and wellness most poignantly (and I paraphrase):

1. Pursue symptomless individuals and tell them what they must do to remain healthy.
2. Be confident that the interventions you espouse will, on average, do more good than harm to those who accept and adhere to them.
3. Attack those who question the value of your recommendations.

In typical Sackett fashion, his tongue-in-cheek pronouncements point the finger of truth directly at those individuals who are arrogant, ignorant and dangerous - but still retain their licenses to practice: "Without evidence from positive randomized trials (and, better still, systematic reviews of randomized trials) we cannot justify soliciting the well to accept any personal health intervention ... to satisfy a narcissistic need for public acclaim or in a misguided attempt to do good, advocate 'preventative' maneuvers that have never been validated in rigorous randomized trials."⁷

The future of chiropractic utilization will be evidence-based and will increasingly depend on the establishment of "gold standards" of care that have withstood the most stringent scientific and methodological challenges.

References

1. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evidence and future implications. J Contin Educ Health Prof,Fall 2004;24 Suppl 1:S31-7.
2. Sackett DL. Clinical epidemiology: what, who, and whither. J Clin Epidemiol, December 2002;55(12):1161-6.
3. Estabrooks CA, Derksen L, Winther C, Lavis JN, Scott SD, Wallin L, Profetto-McGrath J. The intellectual structure and substance of the knowledge utilization field: a longitudinal author co-citation analysis, 1945 to 2004. Implementation Science, 2008;3:49.
4. Bensing J. Bridging the gap. The separate worlds of evidence-based medicine and patient-centered medicine. Patient Educ Couns, January 2000;39(1):17-25.
5. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence-based medicine: what it is and what it isn't. BMJ, Jan. 13, 1996;312:71-2.
6. Arora NK, McHorney CA. Patient preferences for medical decision making: who really wants to participate? Med Care, 2000;38:335-41.
7. Sackett DL. The arrogance of preventive medicine. CMAJ, Aug. 20, 2002;167(4):363-4.