Evidence-Based Medicine:
Best Practices and Practice Guidelines

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

FROM:   J Manipulative Physiol Ther 2007 (Nov); 30 (9): 615–616 ~ FULL TEXT

OPEN ACCESS

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James Winterstein, DC

National University of Health Sciences,
Lombard, IL, USA

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Any thoughtful physician would want to provide the best services for his or her patients, and as far as we know, this has been a precept that has been accepted since the beginning of recorded history as it relates to the practice of healing. This position is one of simple ethical behavior and is part of any vow taken by doctors who practice in one of the branches of medicine. This ethic is characterized by the old and often repeated principle “primum non nocere,” which, interpreted means “first do no harm.”

Although that precept is the foundation for ethical practice, it only speaks to what a physician should not do, and we all know that is not sufficient guidance for a strong patient-based practice. In addition to causing no harm, one who heals must be expected to provide a service that will bring a restoration of optimal health or the maintenance of optimal health, and those are terms which are subject to interpretation.

On what basis does one measure “optimal health”? Clearly, there are hundreds or perhaps thousands of parameters of testing that are routinely applied to humans in the form of various tests and procedures with the intent to use the information gained to help the physician determine the individual's “state of health.” Such parameters of testing are typically based upon an analysis of what would usually be called normal people, but even that term includes some clear pitfalls. What exactly is meant by “normal”? Is a person with 6 digits on one hand, who otherwise shows no evidence of illness, “normal”? If on the other hand we choose to use the word healthy, what does that term mean? Is it generalizable to the patient? How do we describe a person who shows no evidence of other illness, but has a nail fungus? Is that person “healthy”?

Clearly, as the process of healing has become more sophisticated, it has also become much more complex. This complexity is further affected by the insertion of third party payers into the formula, who tend to use various guidelines for the purpose of restriction of practice and limitation of reimbursement rather than in the best interests of patients and their health needs. While we may lament these complicating factors, we must also realize that they are part of our reality in the society in which we live, and once we accept that reality, it is in the best interests of our patients and our profession to develop practices and procedures that are grounded in the accepted epistemology of our time.

When one reads Charles Pierce's article titled “The Fixation of Belief,”1 one can readily discern 4 methods by which, in Pierce's opinion, humans “fix their beliefs,” which we interpret as our method of epistemology—how we come to know that what we “think is true, actually is true.” “Doubt,” says Pierce, “is an uneasy and dissatisfied state from which we struggle to free ourselves and pass into a state of belief; while the latter is a calm and satisfactory state which we do not wish to avoid, or to change to a belief in anything else.”

We are physicians who are committed to helping people gain and maintain optimal human health. In the process of attaining this goal, we develop certain beliefs about that which we do and we hold to those beliefs because they provide a “calm and satisfactory state which we do not wish to avoid, or to change to a belief in anything else.”

Let us look further at the wisdom of Charles Pierce who in his 1877 article clearly delineates 4 methods by which people, including physicians of whatever persuasion, engage in the process of “fixing their belief” in what they do for patients [1]:

1. The method of tenacity — I know this is true because I believe it to be true, therefore it must be true.
   

2. The method of authority — I know this is true because someone in authority says it is true, therefore it must be true.
   

3. The a priori method — I believe this is true because it stands to reason, or it makes sense, therefore it must be true.
   

4. The method of science — I believe this is true because an objective process separate from my way of thinking demonstrates that this is true, therefore it must be true.

We know that scientific experimentation is fraught with various pitfalls, but as an epistemological method, it is far superior to the first three. It brings a stronger sense of “rightful probability” to the equation, which for purposes of this editorial, is the equation that relates to a segment of healing called diagnostic imaging.

In this issue of the JMPT, we have the first phase of a scientific process that has evaluated the use of diagnostic imaging for certain aspects of the practice of chiropractic medicine as it relates to musculoskeletal disorders. The process used has followed accepted guidelines and has depended upon a vast array of scientific literature as well as upon the opinions and inputs of many experts in diagnostic imaging and in the practice of chiropractic medicine. The outcome is a recommended set of guidelines that should prove useful in the best use of diagnostic imaging in assisting physicians in their quest to help patients gain and maintain optimal health.

There will be some within the profession who will resist the application of these guidelines, and there will be some outside the profession who may attempt to use them for inappropriate purposes—that is, the restriction of practice by physicians who, in the final analysis, must have the necessary latitude to do what is best for their patients. However, none of that should diminish our enthusiasm for such guidelines or “best practices,” for they help to define our role in a much more definitive way that helps to enhance our professional credibility and social acceptance. What is necessary, in this entire arena of evidence-based medicine, is a clearly accepted and understood sense of balance that effectively says, “Yes, I know what the guidelines are and in the majority of instances I apply them. However, there are circumstances in which, for the benefit of my patient, I must be provided the ability to deviate from them and I must not be punished for doing so.”

I think that a balanced approach was well stated by Erich H. Loewy, MD, when he wrote, “Physicians must have sufficient elbowroom to deviate for good reason from the current EMB [evidence-based medicine]. EMB has to be seen through the filter of personal training and experience precisely because EBM does not and cannot control for all variables and personal experience provides those variables.” [2]

What we have before us carries significant potential for expansion of cultural authority. We should not be hesitant to embrace the values presented here even while we, as learned physicians, recognize and embrace the values represented in our education and experience. We should seek to use these values in a balanced manner always for the ultimate benefit of our patients.

References:

1. Pierce C.
The fixation of belief.
Pop Sci Monthly 1877;   12:   1–15

2. Loewy EH.
Ethics and evidence-based medicine: is there a conflict?
MedGenMed 2007;   9:   30;[Posted 08/07/07].

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