More practical Evidence-Based Practice for today’s clinician

by Dr. Phil on August 2, 2011

Several years ago, the concept of “evidence-based practice” (EBP) made its way into rehabilitation sciences…the notion that everything we do in practice needs to have evidence to support it. That raised the question then, “what is evidence”?

Practically speaking, “evidence” can give us one of three things: PROVEN, PROVEN NOT, or NOT PROVEN. In other words, research can tell us if something is proven to work, proven not to work, or there’s not enough evidence to tell us either way. In the clinic then, we should focus on using PROVEN interventions, avoiding PROVEN NOT interventions, and using our best judgment when using NOT PROVEN interventions.

Using this philosophy, the first 2 are pretty simple. “NOT PROVEN” interventions, however, should follow the lines of ‘biologic plausibility’. This concept states that something makes logical sense based on our knowledge of anatomy, biomechanics, physiology, etc….and has some ‘path’ from basic science to clinical application. This is the ‘leap of faith’ many use, for example, with animal models to interpret results to humans. Eventually, we hope that an intervention with biologic plausibility can be taken to the next level with outcomes research on actual patients. Note, however, that there are some studies (e.g. in-vitro) which have to be performed on animals that we hope translate into humans because performing them on humans would never get past IRB!

This “NOT PROVEN” area seems to be an intermediate zone compared to the “green means go” PROVEN and “red means no” PROVEN NOT, which leads us to re-think the definition of EBP and move towards a more practical definition for clinicians. I’ve always preferred this definition of EBP that I’ve adapted from several others:

Evidence-Based Practice uses the BEST AVAILABLE evidence with the EXPERIENCE of the clinician and the PATIENTS individual situation.

Bottom line: using these 3 points supports evidence-based clinical decision making! Clinical decision making is the heart of applying evidence in practice. We first rely on evidence, but can’t make all our decisions based on evidence alone. Let’s break those 3 key components in this more practical definition:

  • BEST AVAILABLE: There’s good and bad research, even in published journals. It’s difficult for clinicians to keep up with everything relative to patient care….and even harder to interpret it sometimes. Thankfully, the Internet helps solve that problem, but clinicians still need to stay on top of the latest in practical research.
  • EXPERIENCE: It’s obvious that more experience helps clinicians make better decisions; so-called “Master Clinicians” tend to have better outcomes. In 1992, Gale Jensen and colleagues wrote a great paper on the difference between master and novice physical therapists.
  • PATIENTS: Every patient is different…not just anatomically, but psychologically as well! Experienced clinicians understand that biopyschosocial aspects of rehabilitation are as important as the’ neuromusculoskeletalphysiology’ when it comes to rehabilitation!

Next: Why is EBP difficult for everyday clinicians?

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