Each year I look forward to the combined sections meetings (CSM). The chance to partake of the science of physical therapy, and the catching-up that occurs with my cherished friends, is worth all the packing, lugging, and temptations that occur when I look through the Sky Mall catalog in the plane. Upon receiving the program, I sit with my highlighter and go through the entire schedule to plan my conference days. Often I find myself wanting to go to 2 or 3 presentations that are scheduled at the same time. After making each decision, I then walk about 20 miles, ride several miles of escalators, struggle to find Salon A versus Ballroom A versus Meeting room A, etc. Finally, I settle into a chair prepared to learn. Unfortunately, I am occasionally disappointed in the choice that I make.
The lowlight of CSM for me this year occurred when a speaker expressed the sentiment that clinicians do not need clinical practice guidelines or researchers to tell them what to do in their practice. I could hardly believe what I had just heard. And, even more horrific to me was the fact that some people actually applauded those 2 statements. Those sentiments are such a huge disservice to our profession and I was extremely disturbed that so many students heard such ignorance applauded.
As we all know, our health care system is in the midst of a major overhaul that is destined to reward practitioners who can prove that their interventions are both effective and efficient. The term of evidence-based medicine/practice is now as common to hear from the mainstream media as the explanation from resigning politicians that "I am resigning to spend more time with my family." Indeed, I believe I even heard about an evidence-based twitter last week. Recently I found a definition of the term evidence-based that I like. During an interview on the PBS News Hour in 2009, Dr Donald Berwick stated, "It's making up your mind about what works and what doesn't based on evidence, instead of habit or just beliefs."1 I believe that those who have the best interest of their patients(clients in their minds at all times will appreciate having the guidance that clinical practice guidelines and researchers provide.
Clinical practice guidelines (CPGs) are developed on the basis of the evidence gathered from well-designed research for a defined subject area. In 1997, David Sackett defined CPGs as "...user-friendly statements that bring together the best external evidence and other knowledge necessary for decision-making about a specific health problem."2 In 1990, Woolf referred to CPGs as "a new reality in medicine.3 The National Guideline Clearinghouse employs the definition of clinical practice guidelines that was published by the Institute of Medicine. It states that "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."4
The process for the development of a CPG starts with a clinical practice question. An expert group selects, appraises, and then summarizes the best evidence in the areas of prevention, diagnosis, therapy, harm, and cost-effectiveness. The process culminates with a description of the strength of the evidence. Thomas5 outlined that effective CPGs must have the following criteria:
1. Validity. Each CPG, when used by different practitioners, should lead to predictable improvement. This can be ensured of it is based on rigorous research.
2. Cost-effectiveness. The result of using a CPG should not result in only small improvement for a large cost.
3. Reproducibility. If another group of experts was assembled to develop a CPG for the same question, they would produce the same guidelines and recommendations.
4. Reliability. If 2 practitioners are treating the same clinical problem, the recommendations of the guideline would be applied similarly.
5. Representative development. The expert panel assembled to develop the CPG must be composed of a diverse group of individuals (doctors, RNs, PTs, ethicists, etc)
6. Clinical applicability. The population for whom the CPG is developed must be explicitly defined.
7. Clinical flexibility. The CPG should identify how patient preferences can be taken into account during the decision-making progress.
8. Clarity. The CPG should use precise definitions and a user-friendly format.
9. Meticulous documentation. The guideline should state clearly who was involved in the development of the guideline, the methods employed, the working assumptions, and links to the available evidence with grades assigned to indicate the strength of the evidence.
10. Scheduled review. This will allow the incorporation of new knowledge.
11. Unscheduled review.
Clinical practice guidelines do not tell a practitioner which decisions to make. They identify a range of potential decisions and provide the evidence that, when added to your clinical judgment, and patients/clients' values and expectations, will ensure that the best decision about a plan of care will be decided upon.
After reviewing the philosophy and purpose behind the development of CPGs, I fail to understand the resistance to use the guidance they provide. I do not understand the arrogance of a clinician that believes that they apparently know all they need to know about how to treat a problem. I do not understand why anyone would not want to definitively know which interventions are better than placebo. I also do not understand why some clinicians prefer taking the posture of an ostrich by placing their heads in the sand with respect to research. Why are they afraid to change what they have always been doing when another intervention may have been shown to have a better chance at improving the quality of life of their patient/client.
I would prefer that individuals in the discipline of physical therapy would want to take a "Stand tall" posture so that they can see if there are more effective and efficient interventions on the horizon. We should not be comfortable with only habits and beliefs that are based upon old information. We must accept that we need to be lifelong learners and that research can assist us as we develop plans of care. Being a lifelong learner is an active process. I often hear individuals say that they do not have time during their workday to look for the evidence. I understand that. I am the director of a rehabilitation department and treat both hospital inpatients and outpatients. So I must do some of my learning and searching for the best evidence at night. To those who complain about not being able to search for evidence during an 8-hour workday, I would ask them to observe physicians, nurse practitioners, registered nurses, etc. With the health care system requiring that they see a new patient(client every 15 minutes, when do they read their professional journals. Having a degree in hand, and even a certification framed on the office wall does not mean that learning is complete. Part of being a professional is spending time outside of work reviewing the new knowledge that results from well-designed research.
I believe that when we use available CPGs, our patients are the beneficiaries. The orthopedic section of the APTA recognizes this as they have already completed 6 CPGs. I have chosen to include 1 of the 6 (Neck Pain) in this issue of the journal so that each reader can have a better understanding of their value. The other 5 are readily available on the APTA Web site. I also believe that we need to view researchers not as a threat but as individuals who can help us determine whether the plans of care we develop include interventions that may be more effective that placebo or not treatment at all.
I am hopeful that the Section on Women's Health will someday be involved in the development of CPGs in the areas in which we practice. However, what we have now is the guidance provided by the authors whose manuscripts are included in this issue of JWHPT. From Dr Glenn Irion and Dr Jean Irion you will learn about the use of water immersion to reduce peripheral edema in pregnant women. Dr Ann Dunbar and her colleagues provide information regarding how much women from the general public appear to know about the consequences of vaginal childbirth on the health of the pelvic floor. These researchers do deserve our applause.
Nancy Donovan, PhD, PT
Editor-in-Chief
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