March 30, 2014 by josephbrence for RehabEdge Forum discussion
EVIDENCE-BASED PRACTICE: A PROPOSAL FOR AN UPDATED DEFINITION OF CLINICAL EXPERTISE
Back in the mid-90′s, Dr. David Sackett introduced a model for evidence-based practice (EBP) which was defined as ““the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
His model was built upon the integration of three variables:
Best Research Evidence Clinical Expertise Patient Values and Preferences While these 3 variables were identified as being key ingredients to EBP, I am disconcerted by the amount of weight many have given to #2 when discussing their own models of clinical practice. When Sackett defined this model, what did he really mean when he said “Clinical Expertise”? I went to some of Dr. Sackett’s original work to attempt to understand.
From a 1992 paper on this topic, Dr. Sackett stated:
” Clinical experience and the development of clinical instincts (particularly with respect to diagnosis) are a crucial and necessary part of becoming a competent physician. Many aspects of clinical practice cannot, or will not, ever be adequately tested. Clinical experience and its lessons are particularly important in these situations. At the same time, systematic attempts to record observations in a reproducible and unbiased fashion markedly increase the confidence one can have in knowledge about patient prognosis, the value of diagnostic tests, and the efficacy of treatment.
In the absence of systematic observation one must be cautious in the interpretation of information derived from clinical experience and intuition, for it may at times be misleading.”
In another paper, he described clinical expertise as:
“By individual clinical expertise, we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.”
While attempting to disseminate Dr. Sackett’s thoughts on this subject, I began to suspect we need to update the entire model. While clinical experience is important in improving professional confidence, I am not fully convinced it equates to 1/3 of the model. I actually suspect it leads to cognitive dissonance when the experienced provider is challenged with evidence which is contradictory to their current practice.
It actually appears that his integration of clinical expertise into the early EBP model was a political way to say, “Hey you older docs are doing some ok stuff. But use your expertise in combination with the evolving evidence.” This appears evident when he states, “Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.” Experience is not alone a measure of expertise (this argument actually leads to a genetic fallacy).
Below I have proposed a new provisional model of EBP, utilizing Sackett’s work in combination with my best understanding of current practice.
My Proposed Model of EBP:
Best Research Evidence Patient Values and Preferences Clinical Expertise as defined as: a. Practice built upon clinical reasoning development through measures of introspection, cognition and metacognition (this may be through formal post-graduate residency, fellowship or other formal mentoring opportunities. This will allow for peer-review of your ability to truly reason through clinical work). b. Practice built upon a model of critical thinking that is scientifically defensible and plausible I propose clinical expertise is not simply gained through practice. It is built through assessment of your ability to think, reason and apply scientifically plausible principles into practice. It requires peer-review. It requires your thoughts and ideas to be challenged. It requires a hint of uncertainty.
What do you think? I would love to hear from you guys, and if we can begin to integrate some of these concepts into action!
I'd simply ask if we need #3? If evidence includes science, not just RCTs Id say we don't need 3. How many docs still hand out narcotics for back pain and antibiotics for everything....Testimonials and clinical "experience" have led us to things like graston, craniosacral, MFR, dry needling etc....I'm in favor of anything that keeps us out of that toilet bowl