Problems with evidence based practice

 

To start, it is important that we highlight what evidence-based practice is. Evidence-based practice is a concept imported from medicine in the early 90’s and is meant to be used as a tool to help minimise error in treatment selection when it comes to achieving the best clinical outcomes.  There are three basic principles to evidence-based practice;

 

  • The best available research on a treatment intervention about whether and why it works.
  • The use of a health professional's judgement to assess a patient's condition and the likely benefit of said treatment intervention.
  • Consideration of patients values and beliefs

 

Though, if we were to summarise nicely, evidence-based practice is the application of the best available research in conjunction with the clinician's expertise and judgement. So, what is this supposed problem with evidence-based practice? After all, evidence is confirmation, affirmation, testimony, testament, the metaphorical smoking gun.

 

What are the barriers to evidence-based practice?

In theory, evidence-based practice is the shining beacon of health professions, something we must try to adhere to and stick to as much as possible. It is the supposed “gold standard”. There is a need to draw on both a health professional's clinical experience and the best external evidence while being influenced by our patient’s wishes. Clinical practices can quickly become out of date with the overwhelming amount of evidence that is consistently updated. It can be a delicate balancing act trying to treat patients in the most evidenced supported way by ensuring you have the time to access the evidence itself.

Non-adherence to practice guidelines remains the major barrier to the successful practice of evidence-based medicine. After reviewing the literature, there are consistent themes that arise;

 

  • The findings of clinical research cannot be applied to an individual patient. Every patient is different from the last and the results of a study do not take into account the patient’s own unique circumstances.
  • Clinical expertise and patient preference often override what the evidence may suggest. Patient’s have greater access to clinical information than ever before and may often fall into the realm of being considered an “expert patient” due to the nature of many chronic conditions. A patient may decline treatment that the clinical circumstances indicate is the best course of action.
  • Being able to access the best evidence. Evidence is both numerous and plentiful but where do you start? In addition, unless you have access to a higher educational login, a lot of research will exist behind pay walls. It does not make economic sense to pay for something that may ultimately have no value or influence on your clinical practice.
  • Education about evidence-based practice. A challenge that faces many clinicians is the opportunity to obtain the skills necessary to find and analyse the latest research. This is something that can be resolved via education but again there is a lack of time for the education to take place.
  • Difficulties in developing basic guidelines for some lesser common conditions may exist due to a lack of evidence upon which to base these means progress can be slow.

 

I appreciate the above reasons are not an exhaustive list but they are the ones which frequently arise within the literature. They are but the tip of the iceberg and could be explored in depth quite easily.

 

Too much evidence, too little time

However, there is a need to see past the higher level thinking that has been broached across different literature, podcasts, blogs and other mediums over the years. When you get to the fundamentals of the issue (application of evidence-based practice in the clinical environment) two key issues arise.

The first and most apparent issue is a lack of time. The grim reality is that as soon as we become acquainted with the latest evidence or guidance it won’t be soon before another piece of evidence is published that proclaims to trump what came before it. This is a prolific problem, to such a point that there is evidence about there being too much evidence. There is something of a beautiful irony in this fact. The fact still remains that participating in research is time-consuming when considering the demands of most jobs. On a day-to-day basis, it is low on our list of priorities when needing to deal with the needs of the patient and their family and even colleagues while ensuring we provide the best hands on care consistently. Even with the best of intentions, our time is eaten away by an ever growing list of demands.

 

This is why there is such value in guidelines published by bodies such as NICE which collate the best available evidence into accessible documents that are freely available. However, if we were to be critical of these guidelines, the issue is that they are published and reviewed periodically meaning that when they come to be used/read recommendations can be 3+ years out of date. Guidelines are also not particularly exhaustive. They will not cover every condition and they will not cover eventuality.

 

The second is personal or workplace resistance. There is a tendency to stick to what we know, to use what we trust. This is a cardinal sin in many continuously evolving professions. But when time is a finite resource and the patient is the priority and the patient demand often outstrips the available supply of healthcare we often revert to type. We use the treatment we know has worked 100 times before and in all likelihood will work 100 times again. It is a balancing act often tipped in favour of the patient. For the most part too, the patient does not care about the mechanics of how they achieve better health. Like when most things are broken or not working, we want it fixed, often while being spared the details of how it will be fixed.

 

The journey to improved patient health will vary on an individual basis dependent on a slew of factors. Clinician A may favour treatment X for condition Z while clinician B may favour treatment Y for condition Z. It will be a common scenario that occurs. After all, clinician A has successfully used treatment X to great success before while clinician B has read the latest randomised control trial on treatment Y and its successful  However, if clinicians A and B both achieve improved patient health, can we really argue with successful clinical outcomes?

 

Alex Curran LinkedIn Profile

 

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