When Evidence and Practice Collide

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

FROM: J Manipulative Physiol Ther 2005 (Oct);   28 (8):   551–553 ~ FULL TEXT

Robert D. Mootz, DC

Office of the Medical Director, State of Washington Department of Labor and Industries, P.O. Box 44321 Olympia, Washington 98504-4321, USA


“Until now, we believed that the best way to transmit knowledge from its source to its use in patient care was to first load the knowledge into human minds… and then expect those minds, at great expense, to apply the knowledge to those who need it. However, there are enormous ‘voltage drops’ along this transmission line for medical knowledge.” [1]

-Lawrence Weed, 1999

It sounds good, doesn't it? Evidence-based practice (EBP)—Sackett has characterized it as the conscientious and judicious use of current best evidence in making decisions about the care of individual patients. [2] Key to his conceptions are that individual clinical expertise, best research evidence, and patient values are all factored into clinical decision making. Bolton has furthered the ideal with her contentions that the evolution of EBP requires maturation of both research and practice methodologies to better address the issue of evidence suitability. [3] Key to her conceptions are that EBP specifically involves matching knowledge gleaned from scientifically derived information to individual patient settings, that is, encouraging individual physicians to explicitly seek out and factor in scientifically gained knowledge into daily clinical decision making. Of course, this entails overcoming the inertia of practicing within the “comfort zones” that we have developed based on our training.

Although resources now abound to assist clinicians in the process of incorporating evidence into practice, the reality of information overload still prevails. As of 2004, the National Library of Medicine added almost 11,000 new articles per week to its databases. [4] Just to stay current in internal medicine, an internist would need to read some 20 articles per day 365 days a year. [5] When I began my career, I can proudly proclaim that I owned every chiropractic textbook published by a mainstream publisher and knew personally every chiropractic researcher in the indexed literature. Fortunately, for the science of chiropractic, that no longer holds true. Thus, “relevance retrievability” from the mass of literature has become acutely critical.

Furthermore, the user-friendly secondary information sources such as evidence summaries and clinical practice guidelines we rely on to offset information overload suffer from every limitation human nature conjures up including error, aging, bias, and misinterpretation. Superimposed on all of the impediments individual physicians must overcome are administrative hassles that spring forth from the business and regulatory constraints of contemporary health care. Dichotomous decisions have to be made about what to pay for with pooled public or private resources, balanced among competing demands of the market place. Fig 1 summarizes evidence ideals and realities faced by both clinicians and policy makers. In fact, it is this policy/practice interface where evidence and practice collide. The following 3 conceptual strategies illustrate our challenges.

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