Tearing Down the Pillars of Evidence Based Practice

August 11, 2015 Kenny Venere

One of the most common arguments stemming from our recent post on acupuncture, Needle in the Hay, was that we as a profession should not overly rely on “1/3rd of the pillars of evidence based practice". This argument shows nothing more than a fundamental misunderstanding of what evidence based practice is. The concepts of evidence, clinical experience/expertise and patient values do not exist independently from one another. Nor can we pick and choose which of the three best suits a particular set of beliefs. In fact, we should stop referring to evidence based practice in terms of “pillars” altogether. It is an unhelpful metaphor that only serves to perpetuate a misinterpretation of the philosophy of evidence based practice.

On Parachutes and Evidence

July 11, 2015 Kenny Venere

Smith and Pell’s “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials” has been shared enough times to bolster an argument against evidence based practice that I am compelled to write a blog post about it. For those unfamiliar, Smith and Pell wrote up a satirical randomized controlled trial where one group jumps from a plane with parachutes and the other group uses a placebo parachute. You can guess what the results might be. The issue with the article is that while comical, it is not actually an effective criticism of evidence based practice and its preference for randomized controlled trials over other forms of evidence (such as observational studies).

The Bigger Picture

May 30, 2015 Kenny Venere

In the foreword for Pain: A Textbook for Therapists, Patrick Wall writes

I am convinced that physiotherapy and occupational therapy are sleeping giants [in the treatment of pain].

Wall saw persistent pain and disability as a giant problem that required a giant solution. He could not have been more right. In the United States, pain and disability’s total financial cost ranges between 560 and 635 billion dollars. Despite the public awareness for things like heart disease, cancer, and diabetes, total financial costs for pain and disability nearly exceed all three combined. For context, heart disease costs 309 billion annually, cancer comes in at 243 billion and diabetes is about 188 billion. A large portion of the cost of pain and disability comes in the form of hours and days of work missed as well as the medical costs. As the burden of pain and disability continues to grow, so does the body of literature showcasing our profession’s ability to provide a safe, low cost and effective healthcare provider for those in pain.

In Defense of Evidence Based Practice

April 13, 2015 Kenny Venere

Lately it has appeared en vogue to criticize the evidence based practice movement in physical therapy. While it can be argued that there are a lot of things wrong with evidence based practice, many of the prevalent criticisms on social media seem to stem from limitations in understanding of what evidence based practice is rather than actual shortcomings of evidence based practice itself.

Why Your Expertise Does (and Does Not) Matter

March 13, 2015 Kenny Venere

In his book The Philosophy of Evidence Based Medicine, Jeremy Howick proposes a re-defining of Evidence Based Medicine from:

Evidence-based medicine requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances

to something that better clarifies the role of clinical expertise:

Evidence Based Medicine requires clinical expertise for producing and interpreting evidence, performing clinical skills, and integrating the best research evidence with patient values and circumstances.

This new characterization is carefully crafted to highlight the essential functions of clinical expertise while simultaneously de-valuing its evidential role. Why is such a change necessary? Because clinical expertise in isolation is unreliable in its ability to infer the benefit or harm of an intervention. The uncontrolled observations that contribute to clinical expertise is rife with confounders such as placebo effects, natural history and hasty generalizations. This is problematic when clinical expertise is assigned a significant evidential role when adequate comparative clinical studies are available.