I have seen a growing sentiment on social media that the profession of physical therapy is becoming overly focused on evidence at the expense of empathy, compassion and communication. I believe this to be wholly unsubstantiated and a misguided way to appear more patient centered. The idea that closely adhering to evidence based practice stymies creativity, stunts empathy and promotes a form of clinical autopilot is a false one. Our patients deserve the highest quality care possible and it is evidence that best informs us what that care should actually consist of. Further, the idea that physical therapists follow evidence too closely is thoroughly contradicted by literature assessing adherence to clinical guidelines, use of evidence based interventions and the translation of evidence into practice. If the physical therapy profession has a problem with empathy or lack of patient centeredness, it is not because we are following the evidence too closely.
In 1997, Turner and Whitfield performed a cross national study on physiotherapists use of evidence based practice in which they found “the basis of over 90% of each group's choice of techniques reflected what was taught during their initial training. Experience of treatment effects on prior patients, and information gained in practice-related courses were also primary reasons. Research literature ranked least in importance as a basis for choosing techniques, and review articles fared little better." Numerous studies have been done since then which consistently show that there is a significant knowledge-to-practice gap, limited adherence to clinical guidelines (1, 2, 3, 4), considerable practice variation, a focus on interventions that are not well reported in the literature and a difficulty in letting go of interventions that strong evidence suggests is ineffective, even at higher levels of education and specialization. This is in spite of literature showing that adherence to evidence based guidelines results in improved functional outcomes and less healthcare utilization at least in low back pain (1, 2, 3). Further study is required to generalize these results to other conditions treated by physical therapists.
The reasons for the lack of adoption of evidence based practice are complex and multifactorial — limited access to research, insufficient time, lack of work environment support, deficiencies in the skill and knowledge required to search, obtain and appraise relevant literature as well as a perceived inapplicability of research to individual patients all provide barriers to implementing evidence based practice. Jette et al reported that “nearly 67% of the respondents rated insufficient time as one of the top 3 barriers [to the use of evidence based practice]“ and that 84% of participants felt they needed to increase their use of evidence in daily practice. However, when it came to their ability to critically appraise literature, only “55% of the respondents stated they were confident in their abilities in this skill” and only 66% were confident in their ability to search for relevant literature. Despite generally positive attitudes towards evidence based practice in physical therapy "use of guidelines was not as frequent as could be expected."
So no, physical therapy as a profession is not too focused on the evidence. If there are issues with empathy, communication and patient centeredness, the profession needs to perform honest, scientific appraisals of why this is the case and what brings it about. Physical therapy should leverage the evidence on psychology, motivational interviewing, therapeutic alliance and empathy. Evidence can and should help guide these soft skills that are often thought of as "art." Physical Therapists should also work to improve their scientific literacy, their ability to appraise evidence and seek to adopt real evidence based practice instead of making hasty generalizations from a misconceptualization of what evidence based practice is.
Photo courtesy of the 2015 Alex Garland film, Ex Machina. It is good, go watch it.