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Evidence-Based Care, Certainty, and the Doctor's Duty of Care

      Few topics arouse the passions of today's practitioner like that of the course of health reform and its current trajectory. There is no realm of health care delivery where both patients and providers miss feeling the effects. Even the vaunted cash practice sees its influence through increased patient awareness and questioning of treatment methods using sources such as the Internet and being emboldened to negotiate fees and services in a competitive marketplace. Del Mar et al
      • Del mar C
      • Glaxaiou P
      • Mayer D
      Teaching evidence based medicine.
      suggest the obvious when they say, “Evidence-based medicine is here to stay. It has become an essential way of teaching and practicing in the uncertain world of [small m] medicine.”
      Like most social trends, evidence-based care, originally conceived as a method to inform clinicians and improve patient outcomes, has been propelled beyond its original intent. It has now become evidence-based policy making. In debate, the vanguard of its proponents and its opponents often use stereotypical descriptions that further polarize as they express their views. Some of the more civil exchanges include:
      Opponents: “Nothing is impossible for the man who doesn't have to do it himself.”
      • Freemantle N
      Is NICE delivering the goods?.
      And…
      Proponents: “Having not been tried and found wanting; it has been found difficult and left untried.”
      • McCulloch P
      Half full or half empty VATS?.
      Neither stance reflects the reality of practice.
      Evidence-based care has 2 forms: clinical and regulatory. The clinical form uses best practices that document known risk factors and case complexity to generate expectations of outcome for individual cases. They use methods of monitoring response to care (eg, Visual Analog Scale, Oswestry low back pain questionnaire, Neck Disability Index, etc) and realistic benchmarks for responses to care. If response is adequate, then care should be left unmolested by outside influence. If not, then the doctor should seek to explain it, launching new diagnostic efforts to discover why or to marshal resources altering treatment approach accordingly, and be left alone.
      The regulatory form arises from evidence-based policy making conceived to conserve resources across populations of patients. It seeks certainty in, of all places, the art of applying science and experience in practice. It is the natural tension between these 2 forms that causes conflict for the doctor in meeting his duty to care for individual patients.
      Chiropractic has failed its constituent members—patients, doctors, and policy makers—by running from evidence-based care rather than engaging it, guiding it, and minimizing negative effects on the duty to care for individuals while taking advantage to improve quality of professional performance. Essentially, for the last decade, the profession and its leaders have permitted all other stakeholders in health care to interpret and apply the developing evidence relevant to chiropractic without credible input from chiropractors! As a consequence, subtle changes in the meaning of the evidence convert, for example, the AHCPR recommendation for acute low back care to be manipulation for up to a month only rather than discontinuing care if there is NO improvement within a month.

      Bigos S, Bowyer O, Braen G, Brown KC, Deyo RA, Haldeman S, et al. Acute low back problems in adults. Clinical practice guideline number 14. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub. No. 95-0643; 1994.

      Such input cannot be ad hoc or parochial. It must follow a generally recognized process including standard methods of clinical and scientific evaluation that are patient-centered and minimizes bias if it is to be convincing. What role can chiropractic input take? It can understand the rules of engagement in this conflict and lend its expertise for proper interpretation of the data as it applies to our patients. We need not be fearful. There is good evidence! Our efforts can help refocus policy on individual patient outcome, preserving rational boundaries within which the duty to care for patients can be reasonably practiced.
      The concepts of evidence-based care are hard to oppose. Arrogant and/or ignorant abuses of clinical care and practice-building methods do exist. At the same time, the American Pain Society
      • Lazarus H
      • Neumann CJ
      Assessing undertreatment of pain: the patients' perspectives.
      reports that 45% of households in the United States have at least 1 member who has inadequately treated pain that interferes in his life. Most of them have insurance policies—just inadequate benefit administration. Indeed, it is not the concept but the implementation of evidence-based care that has resulted in significant hardships.
      After 10 years of indignant clamor but deafeningly silent contribution to policy making, is practice to become a remote-controlled cookbook administration of care? Where is the chiropractic voice? As notably expressed by Sackett
      • Sackett DL
      Evidence-based medicine.
      :Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients.
      It is time that the profession reengages and helps to determine its own destiny.

      References

        • Del mar C
        • Glaxaiou P
        • Mayer D
        Teaching evidence based medicine.
        BMJ. 2004; 329: 989-990
        • Freemantle N
        Is NICE delivering the goods?.
        BMJ. 2004; 329: 1003-1004
        • McCulloch P
        Half full or half empty VATS?.
        BMJ. 2004; 329: 1012
      1. Bigos S, Bowyer O, Braen G, Brown KC, Deyo RA, Haldeman S, et al. Acute low back problems in adults. Clinical practice guideline number 14. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub. No. 95-0643; 1994.

        • Lazarus H
        • Neumann CJ
        Assessing undertreatment of pain: the patients' perspectives.
        J Pharm Care Pain Symptom Control. 2001; 9: 5-34
        • Sackett DL
        Evidence-based medicine.
        Spine. 1998; 23: 1085-1086

      Linked Article

      • Evidence-Based Care, Certainty, and the Doctor's Duty of Care
        Journal of Manipulative & Physiological TherapeuticsVol. 28Issue 9
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          Recently, Dr Triano (JMPT 2005;28:215-6) mentioned that, “Evidence-based care has 2 forms: clinical and regulatory.” He states the clinical form “…uses best practices that…use methods of monitoring response to care (eg, Visual Analog Scale, Oswestry low back pain questionnaire, Neck Disability Index, etc) and realistic benchmarks for responses to care.”
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