Wednesday, April 20, 2016

What Is Evidence Based Practice??

You go online or your read an advertisement that says something like "...our _________ work in an evidence-based practice and use the latest evidence to guide our __________."  You read this and may think, "this sounds good" or "sounds like they know what they are talking about." Would you be surprised to hear that evidence-based practice is standard?  So why would a clinic advertise that this is different from everyone else?  Maybe it is their implementation of evidence based practice that is different or the fact that they even do it (an unfortunate statement I know).  So what exactly is evidence-based practice or EBP?

Evidence based practice is the implementation of a practice that involves the melding of best research evidence, clinical expertise, and the values of the patient.  Implementation of evidence-based practice happens in multiple ways but the ultimate outcome is highest quality of care for you in a reasonable amount of time. 

Integrating the best research evidence is not always easy or "perfect."  

It is difficult to conduct a study that is perfect by all standards.  In medicine and health the targets of our studies are people, and as we are all aware, people are not all the same.  We call this variability and variability makes it very difficult to fit one thing to everyone.  Therefore, in research, we try the next best thing.  We try to see if the treatment or outcome fit the majority.  This is where things become a little sloppy because to look at the majority we have to minimize as many confounders as possible.  Things such as researcher bias (wanting to make something true to be famous, financial reason, or personal reason), subject bias (the person being studied wants to be famous, a financial reason, or personal reason), and other influences (too many to list quickly) play a huge role in the outcomes of a study.

Research happens mostly at universities or institutions that have an invested interest in the area.  This can be a good thing but on the flip side it can lead to fudging the numbers.  Now technically we can say that numbers do not lie but you should know that the people who interpret the data do.   Actually integrating the best evidence into practice requires a deep understanding of the strengths and limitations of research.  Without this discernment we can become victim to many of the myths that have perpetuated the headlines (such as eggs will kill you or vaccines cause autism).  That said, we must understand that research is paradoxically both important for advancement of knowledge and sometimes blindly overstated.  The way in which studies are designed also affect their applicability (and data).  In general, all studies should be designed to disprove the hypothesis (i.e. what the research wants to prove or believes will be true).  The best a study can do is to say that the hypothesis (the theory) still stands to be challenged another day.

What we should strive to do is critically look at the research and apply it based on the quality and relevance to the individual. Research should continue to challenge our beliefs. That is why we conduct it, distribute it, read it, and talk about it.

Clinical experience is a very important thing but ask yourself "do they have 1 year of experience 10 times or 10 years of experience?"

I've worked as a clinical instructor and mentor for several years.  The one thing that I see happen repeatedly is that medical and health practitioners become very algorithmic or stuck in following a pattern.  Early on in my career I was told that the most powerful tools I could have were my hands.  I believed this for a long time but now I believe it is the mind. Being able to think and have flexibility allows you to develop, modify, and help each individual.  However, many of you have experienced being treated exactly like everyone else and not getting anywhere.  I would partially blame the current health insurance system for unthinking  medicine by making it all about numbers and profitability.  This does not entirely take the practitioner out of the mix.   The practitioner should be flexible and be able to learn from their failures as much as their successes.  They should be able to admit to making mistakes.  Thinking should not be something only the few do.  Every medical or health professional that you work with should be able to give you a clear thought process on why they are recommending something.  Additionally, they should be able to explain what will likely happen with their plan of care...whether you improve or worsen, what it means and what the next step should be.  This is truly thinking.


Have you ever been to a medical or health practitioner and you felt like they did not listen to you?

You may have said you did not want to take medicine or do certain things and they just ignored you and did not engage you in conversation or offer a compromise.   Maybe they just talked at and not with you.   This is a common thing today.  The current insurance system has led to dehumanizing of medicine by reducing the time someone can spend with you.  However, the practitioner can still maximize the interaction by using intake forms that ask about your life and goals.   This form can help generate a dialogue in this time-constrained environment.  Your other alternative is to choose someone who will spend the time with you.  This is your health and someone should be willing to ask you what you think and/or want.   They should be able to explain to you why your goals are realistic or need modification based on their expertise.  Medical and health practitioners should be there to help you get to outcomes but you are the one that will make it happen. Good practitioners are like coaches that work with you to improve.  They should understand you and be able to work with your individuality and not just your condition or label.   


No one is perfect and your medicine or health practitioner should embrace this.  They should be there to help you achieve whatever it is you want to happen. 

The interaction should be evidence-based practice.  If one of the three aspects is lacking, they should utilize the best of the other areas to help you in the best way.  The practitioner should not ignore one of the aspects and you should always feel like you have a part in your care.   Your belief in what you are doing and having interest is the key to success in health and medical care.  Evidence-based practice is the way a practitioner provides you with the best and most appropriate coaching.   If you are a passive participant, then you will probably get the outcome that is given to you rather than the one you make. It's your health, so choose what you feel is right and make sure you work with someone that can help you in a way that make sense to you and you can truly participate in your health.  

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