The Evidence on Evidence-Based Practice

The following is reproduced with permission from Cinema, a former Twitter personality & blogger who left the social media world about 3 years ago. The reproduction is intended to preserve & share insightful posts from Cinema's blog. This post was originally published in August 2015.

There’s a funny underlying double-standard that exists when conversations arise accusing someone of not playing along with all the thrills & frills of Evidence-Based Practice.

While EBP apologists continually point out the lack of evidence for applying certain techniques and approaches, there is a distinct lack of self-awareness on the porous nature of the majority of medical (& physical therapy?) evidence. In case you missed it, the Editor-in-Chief of The Lancet recently stated,

Much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.

And, Dr. Marcia Angell, who served for more that 2 decades as the Editor-in-Chief of the New England Journal of Medicine says,

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.

Nevertheless, EBP apologists make little haste using words like “woo” and “quackery” with supreme confidence. Does EBP exclude “quackery”? Don’t be so supremely confident of that.

The boundaries between quackery and EBM that clinicians are faced with are not so clear-cut. There is a need for doctors to acknowledge their share in quackery…

Let’s not forget the publication bias toward positive results. We hardly see the ones that didn’t work out. At least some steps to limit this massive bias have been taken. 

Odds are that you’ve already seen this important TED Talk by Ben Goldacre (his fantastic website is a must-read), but in case you haven’t, here’s your chance! The biases, tendencies, and habits mentioned apply across the healthcare spectrum.

Given that up to HALF of all published medical literature could very well be flawed, does it have strong legal standing? Well, not quite.

Evidence-based medicine and the use of CPGs won’t protect patients or physicians from all undesired outcomes or lawsuits, though they can be helpful in defense. They can guide decision-making, but can’t replace experience and judgment.

What about the applicability of published evidence? As Trisha Greenhalgh & company says,

The patient with a single condition that maps unproblematically to a single evidence-based guideline is becoming a rarity.

Well, there you have it. The “E” in EBP doesn’t translate efficiently into the clinic, will not protect you in lawsuits, and has it’s own inherent (even worse, hidden) biases. On top of that, it could make you delusionally overconfident, despite at least 50% of it being false.

What are the odds of these massive gaps existing in Physical Therapy’s published literature? Considering the severe lack of study reproductions, I’d say it’s very high.

If Evidence-Based Practice were a set of clothing you’re wearing, then you’d be no less than half naked.

Look herehere, and here for a few ideas on how to work with the inefficiencies of the “Evidence” in EBP and guide your practice perspective.

– @Cinema_Air

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Jason Boddu