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.
In medicine, there are numerous illustrations of the substandard care that can result when expertise is weighed heavily despite relevant clinical evidence being available. One such example is the slow adoption of the prescription of antenatal corticosteroids to pregnant mothers at risk of giving birth prematurely in clinical practice. Howick details several examples of the eminence that was used to disregard early evidence of antennal corticosteroid’s benefits in this population. This story later became the inspiration for the Cochrane logo and you can read more details here. While this instance was not solely caused by clinical expertise outweighing published evidence, it is illustrative of the problem it can help create. More broadly, a recent systematic review by Choudhry et al actually found that the more years of experience a physician had, the greater their risk for providing lower-quality care.
An example unique to the physical therapy world is the use of outdated passive agents such as ultrasound. The lack of biophysical effects and clinical effectiveness of ultrasound are well documented. In spite of this, a 2007 survey of physical therapists who were board certified in orthopedics found that 83.6% of the respondents were likely to use ultrasound to decrease soft tissue inflammation and 68.8% were likely to use ultrasound to enhance scar tissue remodeling. Again, there are other factors that contribute to an ineffective treatment's continued use, but it is apparent that clinical expertise can readily contribute to the perpetuation of ineffective practices within the world of physical therapy.
This is not to say clinical expertise is useless. Howick actually states the contrary when he writes: “[a]s a skill, expertise pervades all aspects of clinical decision-making and research processes.” There are numerous indispensable roles for clinical expertise in physical therapy. The following are just a few examples.
The observation of an intervention's apparent success is an excellent hypothesis generator, which can later be tested under more controlled conditions. Some of the most important figures in our profession are keen observers. Geoffrey Maitland provides an excellent example of this. Maitland’s uncanny ability as a clinical observer generated many hypotheses in how a patient with musculoskeletal complaints should be treated. This approach has subsequently been tested in various randomized controlled trials such as the ones conducted by Bang and Deyle. As you can see, Maitland’s clinical expertise provided the impetus for a valuable treatment approach that was later properly vetted by comparative trials. The influence of his observations and expertise on how physical therapists manage musculoskeletal conditions is profound.
Interpretation, Implantation and Execution
We have already established that clinical expertise has limited evidential value when comparative trials are available. Where clinical expertise is invaluable is the actual interpretation of published evidence. Having the ability to critically appraise research methods, interpret trial data and other aspects of scientific literacy are paramount to clinical decision making. However, simply being able to dissect a trial’s strengths and weaknesses is not enough. As Kyle Ridgeway states, “knowledge of research does not mean you can apply it.”
A clinician may know from quality published evidence that a canalith repositioning technique is effective for treating Benign Paroxysmal Positional Vertigo. This knowledge is useful in isolation, but to be truly valuable the expertise to identify patients with Benign Paroxysmal Positional Vertigo who are appropriate for the canalith repositioning technique and the subsequent ability to perform the technique is required. To implement and execute knowledge from research in clinical practice, expertise is a must.
Integration of patient values with best evidence
Patient care is complex due to human, environmental and social variability. Therefore, as Jeremy Howick states, “[t]he question of what therapy, if any, the clinician should prescribe is distinct from the question of what the best therapy actually is”. The ability to make sound clinical decisions in the face of ever changing circumstances is a hallmark of clinical expertise. Consider the example Howick provides in his book of an Olympic rower who experiences acute low back pain due to the rigors of the sport the day before the Olympic final. In isolation of patient values and circumstances, the best therapy may involve a cessation of aggravating activities. However, what might be the best therapy is certainly not the most acceptable or effective therapy for this particular athlete. An expert clinician can seamlessly integrate best evidence with patient values and circumstances to deliver optimal care.
Expertise and therapeutic alliance
A clinician who is empathetic, actively listens and provides appropriate reassurance to their patient is demonstrating clinical expertise. Recently, there has been an influx of research in the physical therapy world and in medicine suggesting that therapeutic alliance can be a potent modulator of therapeutic effects. In 2014, Fuentes et al looked to compare the effects of enhanced versus limited therapeutic alliance on pain intensity in patients with chronic low back pain receiving interferential current (IFC). They divided subjects into four groups as seen below:
What they found was that patients in the enhanced therapeutic alliance groups (both active and sham interferential current) showed a greater reduction in pain intensity than those in the limited therapeutic alliance groups. They also saw a dose-response relationship in that the Active interferential current+Enhanced Therapeutic Alliance showed the largest reduction in pain intensity and the Sham interferential current +Limited Therapeutic Alliance group showed the smallest reduction of pain intensity.
This growing body of evidence highlights the role of clinical expertise in providing compassionate and individualized care. An expert clinician is someone who actively listens, allows for the full expression of a patient’s complaint, and is able to stop short.
There are endless examples of the necessity of clinical expertise in what we do as physical therapists. To move forward as profession, we should adopt Howick’s re-definition of Evidence Based Medicine. This means recognizing that clinical expertise has a limited evidential role and embracing the fact that expertise has essential functions elsewhere in physical therapy.
Interested in more on clinical expertise? Be sure to check out Howick’s book The Philosophy of Evidence Based Medicine, it is fantastic. Erik Meira, Joe Brence and Kyle Ridgeway have also written on this topic. You can read Erik’s post here, Joe’s here and Kyle’s here.
References and Further Reading
Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30: 126–37
Baker, K. G., Robertson, V. J., & Duck, F. a. (2001). A review of therapeutic ultrasound: biophysical effects. Physical Therapy, 81(7), 1351–8.
Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005 Feb 15;142(4):260-73.
Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes DD, et al.Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301– 17.
Howick, J. (2011). The philosophy of evidence-based medicine. BMJ Books.
Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M. A., Dick, B., Warren, S., … Gross, D. P. (2014). Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients With Chronic Low Back Pain: An Experimental Controlled Study. Physical Therapy, 94(4), 477-489.
Robertson, V., & Baker, K. (2001). A Review of Therapeutic Ultrasound: Effectiveness Studies. Physical Therapy, 1339–1350.
Wong, R. a, Schumann, B., Townsend, R., & Phelps, C. a. (2007). A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists. Physical Therapy, 87, 986–994. doi:10.2522/ptj.20050392
Photo courtesy of Chris Pirillo