Selecting Treatments: Healthcare Education

While not all of us are going to be involved in training students in the use of therapeutic interventions and treatment, the work we do here is geared toward making that happen. In the evidence-based world, how does one go about selecting treatment? Sackett and colleagues (1) offer some thoughts.

They proceed from the decision that you have reached a point where you believe the patient’s condition does warrant treatment (and there are many reasons why you may not). And further, you have selected the goal of treatment; in the case of a chiropractic physician, it may be to decrease pain, to lessen disability, or something else. But now you need to select the appropriate and proper therapy (whether adjustment, exercise, counseling, or so on). According to Sackett, there are three ways to choose the intervention:

1. You consider your own uncontrolled clinical experience and of your colleagues and friends, or perhaps you extend certain concepts of mechanisms of disease so that you arrive at a therapy that “seems to work or ought to work.” This is an inductive approach to therapy.

2. You obtain clinical research papers, mainly comprised of clinical trials which are designed to expose worthless or dangerous treatments, and you select treatments that “are able to successfully withstand formal attempts to demonstrate their worthlessness.” This is a deductive approach to therapy.

3. You obtain recommendations from your teachers or colleagues, or from advertisements and you then accept the treatment “on faith.” Sackett refers to this as the method of abdication or of seduction.

Now, it will not come as a surprise that Sackett and colleagues prefers the method of deduction. They argue that using your own clinical experience carries risks that you may not be aware of, notably that what you are really doing is using “historical controls.” By this, they mean that when you compare your latest patient to those you have seen before and for whom you were able to treat successfully, you may be comparing your current and potentially new treatment to an older form of therapy. And if you are able to help the current patient, you judge this new approach as efficacious and superior. In this they see risk.

However current formulations of evidence-based care recognizes that clinical experience is one plank of a triple-planked construct: best available evidence from the literature, combined with clinical expertise and patient values. All are important. But as I see evidence-based care, we need to stay mindful that one of the most common reasons for using it is to determine what to do for a patient where we have questions about what to do; that is, for situations where we might not know what to do. In such cases, our past clinical experience may not be much of a guide. I like to use the example of Brucellosis (in fact, I will hear from a certain academic administrator cough cough Dr. Weinert cough cough for using this example). This is not typically seen in chiropractic settings, so when you are confronted with a patient with this condition, how would you proceed? You would not have clinical expertise in managing the condition. Thus, you would likely need to turn to the literature for best information. When you do have experience, well, that experience will tell you what to do.

Conversations such as this are important in understanding the basis for modern practice, and the literature is replete with them. I heartily urge readers to look into the philosophical basis for evidence-based practice.

References
1. Sackett DL, Haynes RB, Guyatt G, Tugwell P. Clinical epidemiology: a basic science for clinical medicine, 2nd edition. Boston, MA; Little, Brown, 1991