reflections of clinical expertise and EBP

Reflections on CHAPTER Clinical Expertise and Evidence- Based Practice Ruth Grant Taking time to stand back and reflect is always important, particularly at the beginning of a new century. The intent of this chapter is to capture some reflections on the changing nature of work, the exponential increase in access to information, and the way that knowledge is valued, managed, and used. It also reflects on the centrality of lifelong learning for health and growth not only of an individual, but also of a profes- sion, and reflects on the synergy, or lack thereof, between clinical practice and the evi- dence base for it. CHANGES IN THE NATURE OF WORK Technological change and other changes stemming from the globalization of econo- mies around the world are now having a profound effect on the nature of work in its broadest sense: the way it is organized and the skills it requires.' These changes are now so rapid that many students graduating from universities today can be expected to have up to five distinctly different careers in their working lifetimes. They may also anticipate that their working life span may be shorter, with a greater portion of their life spent in active retirement. They are keen to learn, acquire new knowledge, and particularly age successfully. Further change is predicted by Ellyard'' (a futurist and strategic analyst) in his book, Ideasfor a NewMillennium, published in 1998. Ellyard states, \"If one looks at the rates of globalisation and technological change ... it seems reasonable to deduce that in the next 25 years, up to 70 per cent of all job categories are likely to change, half of the existing job categories will disappear, the other half will consist of new jobs that do not yet exist. Other jobs will keep their present names but the nature of the work will change.t\" For example, numerous changes have occurred in the banking industry because of technological change; this is particularly true about the job of a bank teller. In the banking industry the cost of a transaction at an automated teller machine or over the Internet is one-twentieth that of an over-the-counter transaction at the bank. Using this example, we can begin to see why Ellyard/ was prepared to predict the future of work in the way that he did. 413

414 Chapter 2 I Reflections on Clinical Expertise and Evidence-Based Practice Where would we place the physical therapy profession in Ellyard's prediction? As physical therapists, we would no doubt place our profession in Ellyard's last category: our titles may remain the same but the nature of our work will change. However, 25 years from now, will our profession have been very successful in establishing a sound and comprehensive clinical research base for diagnosis, assessment, and treatment to ensure a continuing professional relevance and vital contribution to patient care? Or will the changes not be of our making and serve to constrain the profession? To what extent, a quarter of a century from now, will clinicians have access to, and have adopted, the outcomes of sound research so that evidence-based practice will be the norm? To what extent will the decision making by physical therapists in the manage- ment of their patients continue to be based predominantly on clinical experience and biomedical or pathophysiological explanations? The challenge is that the evidence base remains to be established for much of the practice of medicine as well as of physical therapy. Sackett et at,3 writing in 2000, stated that \"conventional wisdom\" had it \"that only about 20% of [medical] clinical care was based in solid scientific evi- dence.\" Estimates of the extent to which physical therapists are currently practicing evidence-based diagnosis, assessment, and treatment are unknown. CHANGES IN ACCESS TO AND AMOUNT OF INFORMATION The exponential growth in access to information is already a feature (and will con- tinue to be a feature) of life in the twenty-first century. The implications of this fact are staggering. Although it took 34 years for 50 million people worldwide to have ac- cess to the radio and 15 years for the same number of people to have access to tele- vision, it has taken only 4 years for 50 million people worldwide to become users of the Internet. Traffic on the Internet is estimated to double every 100 days; seven people become Internet users every second. It was predicted that 1 billion people would be using the Internet in 2001.4 In an analysis of how users used the Internet, it was found that 88% used it to get information, 83% to communicate (i.e., e-mail), 80% to do research, and 75% to \"surf the Net.,,4 Not surprisingly, many of the people surveyed used the Internet for more than one of these purposes. Biomedical and health information via the worldwide web is one example of the knowledge explosion. Patients will increasingly expect their health care provider of whatever persuasion to have up-to-date knowledge of their condition, the efficacyand risks associated with different treatment approaches, and perhaps even the evidence base for the choice of treatment recommended or given-information the patients themselves can access from the web. The exponential growth in access to information globally has the potential to change a profession. A proftssion or proftssional group may be defined as a group having knowledge that is not available to others; a professional knowledge base sets that profession apart from others. As health information becomes increasingly accessible to patients, a lot of knowledge will no longer be unique to a profession; in fact, much of this information (e.g., disease processes, interventions and associated risks, medications, and therapies in both conventional and alternative medicine) is already available on the Internet. As a result, our patients may be better informed than ever before. When a patient is well informed, the partnership between the therapist and patient can be enormously pow- erful and the patient's own sphere of influence as a healthy lifestyle advocate very pro- found. Knowing simple key facts about nutrition and exercise, for example, can sig- nificantly affect a patient's health and morbidity. Thus access to the \"information

Changes in ways of Accessing Information 415 superhighway\" and the resultant increase in patient knowledge can challenge the defi- nition of profession in interesting ways and may change the concept of professional responsibility. One of the truly great challenges that physical therapists face (along with other health professionals) in the twenty-first century is keeping up-to-date with clinically important new information relevant for the way they diagnose and treat patients, not least because of the sheer volume of clinical and relevant biomedical literature. For example, in 1955, there were just two randomized controlled trials of physical therapy.'t\" In Afri12001, there were 2400 listed on the Physiotherapy Evidence Da- tabase (PEDro) of the Centre for Evidence-Based Physiotherapy at the University of Sydney. (Web addresses for all databases referred to in this chapter are given at the end of the chapter.) The volume of clinical literature in medicine was so big in 1995 that Davidoff et al8 estimated that general physicians who wanted to keep abreast of the journals rel- evant to their practice would have to examine 19 articles a day, 365 days a year. How- ever, from polls of medical grand rounds' audiences at a number of medical schools in the United Kingdom, Sackett et al9 found that 75% of medical interns had not read anything about the problems presented by their patients in the previous week and were being taught by senior consultants, up to 40% of whom also had not read any- thing in the previous week. Even self-reports of medical clinicians' average weekly reading times showed (perhaps not surprisingly) that there was simply no way that medical practitioners could keep abreast of their fields of medicine using traditional approaches, such as perusing journals. This situation, we could predict, is by no means unique to medicine. The constant but unfilled need for clinically important new information leads to a progressive decline in clinical competence. (Again, the medical profession has been the most intensively researched in this respect.) This progressive decline has been shown in medicine in the knowledge about the care of hypertension, for example. Evans et allO and Ramsey et alII demonstrated a statistically and clinically significant negative correlation between medical practitioners' knowledge of up-to-date care of hypertension and the years that had elapsed since graduation from medical school. Significantly, Sackett et al9 showed that the decision to start antihypertensive agents in these patients was better predicted by the number of years since graduation from medical school than by the severity of the target organ damage in the patient. CHANGES IN WAYS OF ACCESSING INFORMATION Globalization and technological change have resulted in an exponential increase in access to information concomitant with a knowledge explosion. Health professionals, including medical practitioners and physical therapists, struggle to keep abreast of the published literature relevant to their practice. Health information is now more acces- sible via the Internet than ever before, and it is available to all who have an interest in it: health professionals, patients, and members of the general public. For the clini- cian, keeping up-to-date now clearly requires electronic information-searching skills (or access to others with these skills) and critical appraisal skills, particularly for the evaluation of published clinical research trials found through searches; this is in addi- tion to the time needed to keep up-to-date. Interestingly, Ellyard/ proposes a new professional: the \"knowledge navigator.\" Technology, Ellyard argues, is making the old demarcation between teacher and li- brarian more and more blurred. The knowledge navigator emerges from an integra-

416 Chapter 2 I Reflections on Clinical Expertise and Evidence-Based Practice tion of the traditional role of teacher and librarian. Knowledge navigators, Ellyard 2 states, \"could assist learners [clinicians) to seek and find knowledge by gaining access to a wide variety of knowledge resources and to enrich and affirm that knowledge and learning where appropriate. There is also another future role ... as a mentor who is responsible for assisting and inspiring personal development.\" Even though they have yet to emerge as a distinct professional group, knowledge navigators already exist. It is vital that physical therapists use them and the services they offer. Much is being done (and much of this is closely aligned with evidence-based practice) to assist the clinician to quickly and efficiently locate the best evidence to in- form practice. The PEDro database is an excellent example of the work of knowledge navigators, although the physical therapists responsible for developing, maintaining, and extending PEDro in the Centre for Evidence-Based Practice at the University of Sydney would probably not yet be familiar with the term. PEDro provides physical therapists (and others) with the most comprehensive database of physical therapy clinical trials, including randomized controlled trials and systematic reviews. Impor- tantly, this site provides for the user, publications that have been critically appraised and given a quality rating. The database includes over 1700 randomized controlled trials, approximately 250 systematic reviews, and over 200 other papers. The knowl- edge navigators who created PEDro have also identified core journals of evidence- based physical therapy practice and ranked them by trial quality.12 CHANGES IN PRACTICE: EVIDENCE-BASED PRACTICE Thompson-O'Brien and Moreland19 define evidence-based practice as the process of us- ing the results of sound research (as determined by critical appraisal) to guide clinical care within the context of the individual client and local environment. Sackett' (the \"father\" of evidence-based medicine) defines it as \"the integration of best research evidence with clinical expertise and patient values.\" For many physical therapists (and indeed medical practitioners) evidence-based practice has tended to become synonymous with clinical practice treatment choices determined by evidence from randomized controlled trials and from systematic re- viewsin such a way and to such an extent, that the clinician's clinical experience and the patient's individual needs and values take second place. Support can be found for this view in that although there has been a large increase in the number ofrandomized con- trolled trials, there is still not enough evidence to comprehensively guide practice or to answer many clinical questions. Furthermore, the evidence available is often not of suf- ficient quality to guide clinical decision making. Indeed, it may be argued that random- ized controlled trials generally measure outcomes deemed important by the researcher and are less likely to include outcome measures that patients deem important. 13-18 This is why it is important to remember Sackett's definition of evidence-based medicine (\"the integration of best research evidence with clinical expertise and patient values\"). By best research evidence, Sackett et a13 mean clinically relevant research, es- pecially from patient-centered clinical research into, for example, the accuracy and precision of diagnostic tests or the efficacy of particular treatment approaches. This is only one of the key components of Sackett's definition. Clinical expertise and patient values are also key components. Clinical expertise is \"the ability to use our clinical skills and past experience to rapidly identify each patient's unique health state and diagno- sis, their individual risks and benefits of potential interventions and their personal val- ues and expectations,\" and patientvalues are \"the unique preferences, concerns and ex- pectations each patient brings to a clinical encounter, and which must be integrated

challenges for Establishing EVidence-Based Practice 417 into clinical decisions if these are to best serve the patient.\" These authors then go on to emphasize, \"When these three elements are integrated, clinicians and patients form a diagnostic and therapeutic alliance which optimises clinical outcomes and quality of life.\" Thus an adherence to the outcomes of randomized controlled trials of physical therapy alone in patient management would not in itself be evidence-based practice. Attention to clinical expertise and patient values is critical as well. Many clinicians fear that use of an evidence-based practice approach equates with a downgrading of clinical expertise and attention to patient needs and values; the defi- nition by Sackett et al3 should allay such fears. It remains very important however, that physical therapists know how to access best evidence where this is available and to in- corporate it in their care of patients whenever possible. Where such an evidence base does not exist, the physical therapist needs to ensure that clinical decision making is based on a systematic, critically evaluative examination, treatment, and assessment ap- proach and is based on up-to-date biomedical knowledge and pathophysiological con- siderations. The practicing clinician also needs to be able to ask key questions of criti- cal clinical relevance so that knowledge navigators can explore them and particularly so that researchers within the profession can address them. CHALLENGES FOR ESTABLISHING EVIDENCE-BASED PRACTICE Sackett et al3 have identified four \"realizations\" that explain the rapid spread of evidence-based medicine and that have been attested to by practicing clinicians. (These realizations are just as relevant for manual therapists or physical therapist cli- nicians as they are for medical practitioners.) They are as follows: • A daily need for valid information about diagnosis, prognosis, treatment, and pre- ventative measures • The inadequacy of traditional sources for this information because they \"are out of date (textbooks), frequently wrong (experts), ineffective (electronically delivered continuing professional education) or too over whelming in volume, or too variable in their validity for practical clinical use (medical journals)\"! • The disparity between diagnostic skills and clinical judgment, which increases with experience, and up-to-date knowledge and clinical performance, which appear to decline with experience • The inability to set aside more than 30 minutes per week for relevant reading and study and a virtual inability to be able to find and assimilate the latest evidence when with patients These realizations or challenges, it could be argued, are almost too overwhelming for busy clinicians in full-time practice if they are to be able to identify the current evidence base (or lack thereof) for what they do and to be better informed. The fol- lowing actions are strongly recommended to help professionals develop and use an evidence-based practice approach: 1. Use scarce reading time wisely. For example, identify a clinical problem commonly seen in practice (rather than a rare one) and specifically devote reading time to be- come familiar with the evidence base for its treatment. Using scarce reading time to browse through professional journals for evidence one hopes to recall when it is needed later is not the best use of this time. 2. Have or rapidly develop information-search skills and Internet-access skills. If cli- nicians are to use scarce reading time effectively, they must develop basic search skills, computer literacy, and Internet-access skills. Mature clinicians without these

418 Chapter 2 I Reflections on Clinical Expertise and Evidence-Based Practice skills can arrange for a \"knowledge navigator\" to assist them. (Examples are a fac- ulty member at the physical therapy school, a librarian at the university library, a clinician with advanced search skills and with similar interests in the area of physi- cal therapy practice.) Many physical therapists are familiar with MEDLINE (the largest biomedical database), and many begin their searches there. MEDLINE is available on the In- ternet and is free. It may be accessed through the search engine PubMed, which has a user-friendly search interface; simply typing in physical therapy, neck pain, and clinical trial in the search window, for example, allows a thorough search of these topics. However, many physical therapy journals are not available on MEDLINE but are indexed in another biomedical database, Cumulative Index to Nursing and Allied Health Literature (CINAHL). CINAHL also requires access through the search engine Ovid, which unlike PubMed, requires user fees. Most biomedicalli- braries provide access to Ovid because it opens the door to a number of databases (CINAHL and EMBASElExcerpta Medica amongst them) and to a number of secondary information sources or distilled information sources (see point 4). 3. Develop skills to critically appraise clinical research. Many recent physical thera- pist graduates have critical appraisal skills. Many mature physical therapists, expe- rienced clinicians though they may be, may not. This provides an opportunity for a group of similarly placed clinicians to organize customized continuing profes- sional education to achieve such skills. There are useful published articles (e.g., Greenhalgh/\" and Guyatt et aI2!), and the excellent book by Sackett et al3 is also invaluable. The second edition has a CD that contains clinical examples, critical appraisals, and background papers from 14 other health disciplines, including physical therapy. These examples can be substituted for the medical practice ex- amples and critical appraisals in the book as one learns about integrating evidence- based practice in one's own clinical setting. There are also Internet sites that help with the critical appraisal of studies, including the Centre for Evidence-Based Physiotherapy (which maintains the Physiotherapy Evidence Database, PEDro). PEDro also has a tutorial to educate users about study validity. The importance of educating clinicians to be critical consumers of published clinical research is illustrated by the following example. An intensive evidence- based practice, week-long workshop is a core component of the studies for physical therapists undertaking the advanced specialization Master of Physiotherapy degree at the University of South Australia (in manipulative physiotherapy, sports physio- therapy, or orthopedics and manual therapy, for example). Successful completion of the assessments integral to the workshop results inter alia, in these graduate stu- dents becoming accredited PEDro critical appraisers (and early knowledge naviga- tors, to use Ellyard's term). Given that the majority of the physical therapists un- dertaking these Masters programs are international students, the benefits are extending well beyond Australian shores. 4. Be familiar with distilled literature sources or secondary sources of information in which research studies have already been critically appraised. The important things to know are what these sources are and how to access them. A recently published special issue of Physiotherapy Theory and Practice on evidence-based practice 22 is strongly recommended because it introduces the physical therapist to these dis- tilled literature sources. Particularly recommended in this regard are the papers by Walker-Dilks23 and O'Brien.24 Walker-Dilks/? states, \"Distilled literature sources are becoming popular be- cause they are fast and easy to search, the content has been reviewed for quality and

Conclusion 419 the information is presented in a more usable format.\" Amongst these sources is the Cochrane Database of Systematic Reviews. Abstracts of these reviews (which summarize and report evidence from clinical trials) are freely available at the Cochrane Website. In addition, there is the Controlled Clinical Trials Register, which is also under the Cochrane banner. Importantly, these include trials reported in journals not indexed in MEDLINE. The Cochrane Library is the electronic source of secondary information produced by the Cochrane Collaboration, an in- ternational organization that prepares, maintains, and disseminates systematic re- views of controlled trials. One important \"field\" of the Cochrane Collaboration is \"Rehabilitation and Related Therapies.\" Secondary sources of information also include abstract journals. Only high- quality studies that meet defined criteria are included, and these are presented in a structured abstract form. Evidence-Based Medicine is one of these. It is a joint publication by the American College of Physicians and the BMJ Publishing Group; another is the ACP journal produced by the American College of Physicians. Both of these abstract journals are available in CD form in Best Evidence, which is up- dated annually. It is important to realize that a number of these distilled literature sources need to be accessed using a front-end search engine that requires user fees. Ovid is such a search engine that provides, through its \"Evidence-Based Medicine Reviews,\" access to not only Best Evidence but also the Cochrane Database of Sys- tematic Reviews. User fees may be prohibitive for clinicians, but many libraries provide this access. Walker-Dilks23 states that some journals are now including structured abstracts within their individual issues; these are often accompanied by a commen- tary from an experienced clinician or expert in the field. Three examples are the Critically Appraised Papers (CAPs) section of each issue of the Australian Journal ofPhysiotherapy, the Evidence-Based Orthopedics section of the JournalofBone and Joint Surgery (American volume), and the Patient-Oriented Evidence that Matters (POEMs) component of the Journal of Family Practice. The Internet also provides excellent secondary sources of information such as the Physiotherapy Evidence Database (PEDro). Finally, it is important not to for- get that the second edition of Evidence-Based Medicine by Sackett et al3 also has its own website. This website will update the book's contents and resource lists as new evidence or strategies come to light. It also provides links to other evidence-based websites and resources. CONCLUSION Many challenges remain. First, when physical therapists do not have comprehensive evidence from randomized controlled trials of physical therapy interventions or well- designed qualitative studies for guidance, they should ensure that they are using vali- dated outcome measures in determining the effects of treatment. They need to be careful wherever possible to ensure that the assessment and treatment approaches used are based on good clinical research. When this is not possible, they need to en- sure that they are systematic in clinical decision making and that the treatments pro- vided for patients are based on sound biomedical and pathophysiological knowledge. Second, physical therapists engaged in clinical research must ensure that they get the evidence from sound research to the clinician and into clinical practice. Third, they need to be cognizant of the fact that, overwhelming though the logic may be, there

420 Chapter 21 Reflections on Clinical Expertise and Evidence-Based Practice is no clear evidence as yet, that evidence-based practice improves quality of care. Physical therapy as a profession will prosper in the twenty-first century if physical therapists pay due heed and ensure that their practice \"integrates the best research evidence with clinical expertise and patient values.\"? References 1. Rifkin]: The endof work, New York, 1995, GP Putman's Sons. 2. Ellyard P: Ideas for the new millennium, Melbourne, 1998, Melbourne University Press. 3. Sackett DL, Straus SE, Richardson WS et al: Evidence-based medicine, ed 2, Edinburgh, 2000, Churchill Livingstone. 4. Dolence MG: Emerging strategies for 21st century higher education: condition report, Global Learning Systems, Clarememont, Calif, 2001, Michael G Dollenz and Associates. 5. Coyer AB,Curwen IH: Low back pain treated by manipulation: a controlled series, BrMed ] 1:705, 1955. 6. Harris R, Millard ]B: Paraffin-wax baths in the treatment of rheumatoid arthritis, Ann Rheum Dis 14:278,1955. 7. Sherrington C, Moseley A. Herbert R et al: Guest editorial, Physiother Theory Pract 17:125, 2001. 8. Davidoff F, Haynes B, Sackett D et al: Evidence based medicine: a new journal to help doctors identify the information they need, Br Med] 310:1085, 1995. 9. Sackett DL, Richardson WS, Rosenberg W et al: Evidence-based medicine, ed 1, Edinburgh, 1998, Churchill Livingstone. 10. Evans CE, Haynes RB, Birkett NJ et al: Does a mailed continuing education program im- prove clinician performance? Results of a randomised trial in antihypertensive care,]AMA 255:501,1986. 11. Ramsey PG, Carline]D, Inui TS et al: Changes over time in the knowledge base of prac- ticing internists,]AMA 266:1103,1991. 12. Maher C, Moseley A. Sherrington C et al: Core journals of evidence-based physiotherapy practice, Physiother Theory Pract 17:143,2001. 13. Di Fabio R: Myth of evidence-based practice,] Orthop Sports Phys Ther 29:632, 1999. 14. Feinstein AR, Horwitz RI: Problems in the \"evidence\" of \"evidence-based medicine,\" ]AMA 103:529, 1997. 15. Greenhalgh T: Narrative based medicine: narrative based medicine in an evidence based world, Br Med] 318:323, 1999. 16. Herbert RD, Sherrington C, Maher C et al: Evidence-based practice: imperfect but nec- essary, Physiother Theory Pract 17:201, 2001. 17. Ritchie ]E: Using qualitative research to enhance the evidence-based practice of health care providers, Aust] Physiother 45:251, 1999. 18. Ritchie ]E: Case series research: a case for qualitative method in assembling evidence, Physiother Theory Pract 17:127, 2001. 19. Thompson-O'Brien MA. Moreland ]: Evidence-based information circle, Physio Can 50:171,1998. 20. Greenhalgh T: How to read a paper: assessingthe methodological quality of published pa- pers, Br Med] 315:305,1997. 21. Guyatt GH, Sackett DL, Cook D]: User's guide to the medical literature. II. How to use an article about therapy or prevention: are the results of the study valid?]AMA 270:2598, 1993. 22. Physiotherapy Theory and Practice, 17(3), 2001. 23. Walker-Dilks C: Searching the physiotherapy evidence-based literature, Physiother Theory Pract 17:137, 2001. 24. O'Brien MA: Keeping up-to-date: continuing education, practice and improvement strat- egies, and evidence-based physiotherapy practice, Physiother Theory Pract 17:187, 2001.

References 421 Websites American College of Physicians: http://www.acponline.org/journals/acpjc/jcmenu.htm Best Evidence CD (updated annually): http://www.acponline.org/catalog/electroniclbesc evidence.htm BM] Publishing Group and the American College of Physicians: http://ebm.bmjjournals.com Cochrane Database of Systematic Reviews: http://www.update-software.com!cochrane/ cochrane-frame.html (This is within the Cochrane Library, which also includes the Con- trolled Clinical Trials Register.) MEDLINE through PubMed: http://www4.ncbi.nlm.nih.govlPubMedl Ovid (which requires a user fee): Ovid: http://www.ovid.com!(The site includes a Cumulative Index to Nursing and Allied Health Literature [CINAHL] and EMBASElExcerpta Medica.) PEDro: http://www.cchs.usyd.edu.aulpedro/ Sackett et al: Evidence-based medicine, ed 2: http://hiru.mcmaster.calebm.htm