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Editor's Notes |
The Lady of Justice carries her scales perpetually balanced, even as she remains blind to bias and political pressures—or so we would like to think. Too often, the reality is far from the imagery. Some decisions are made in the absence of evidence; others are made in spite of it. Perhaps the statue that carries the scales should be accompanied by another statue, one devoid of blindfolds: a Lady of Astonishment, who looks on in disbelief or grief at what she sees.
I'm sure that most of us can recall at least one potentially egregious miscarriage of justice. Our outrage often is directed at those we believe are most culpable: the lawyers. Lawyers are supposed to be advocates—and they are supposed to function within boundaries. Neither side in a judicial dispute can alone find the truth. The two-sided process is intended to lead to a reasonable approximation of truth and justice, and, in the case of criminal cases in the United States, to err (if there must be error) on the side of the accused.
Most of us health care professionals try to distance ourselves from the lawyers, but we reach new heights of hypocrisy when we malign them. How about us? Are physical therapists the sole arbiters of what should and should not occur in terms of patient care? The organizations that manage not care but cost may believe that they are above the need to justify their actions. What gives us the right to say that we know better? Why has the search for data become an adversarial rather than a cooperative effort?
Three years ago our profession lost a great presence when Eugene "Mike" Michels, former president of both APTA and the World Confederation of Physical Therapy, died. His words remind us of how physical therapists and physical therapist assistants can indeed be a moral force for the good of patients, rather than capricious guardians of the status quo and undeserved arbiters of what is "good." Mike was an advocate of open discussion and believed that our profession suffered from a lack of people who would ask questions of those who claimed to have all the answers. And Mike had been around long enough to remember how many times we thought we had all the answers! Williams' flexion exercises, for instance, were once viewed as our professional salvation, as the technique that would meet our patients' needs. In his 1968 presidential address, Mike reminded us that "having differences is not necessarily symptomatic of disease. It can lead to a search for a new equilibrium—a new homeostasis—for it is the nature of the living to make changes, to adjust, and to adapt. The temporary illness—the upset—may lie in the way people attempt to bring these changes about."1
Mike saw the flaw in behaviors that were justified primarily by the arguments of so-called experts and by seemingly endless anecdotes. He felt that too often we failed to appreciate a critical part of our professional mission: to test and evaluate instead of merely endorsing.
In seeking change, the patience, time, and skill needed to use existing mechanisms are frequently discarded in favor of what are hoped to be more direct and immediate methods. Instant demonstration and instant action have joined with instant foods, instant beverages, instant-on television, and instant communication to replace motherhood, love of God and country, and apple pie as symbols of our current culture....
We must be rational not emotional, convincing not demanding, understanding not vitriolic, and we must be willing to work for change rather than hoping to suddenly create it. We must say what we honestly think and we must listen honestly when others say what they think.... We must promise only what we can deliver and we must deliver what we promise.1
Recently there has been much debate about how we can know whether we deliver. This is where outcomes research plays a role—as do clinical trials. More often, clinical trials have a greater focus on individual patients and responses to interventions. Mike saw what harm we do when we profess to know what's best in the absence of evidence or, worse yet, in the presence of evidence that contradicts our beliefs:
...what most seriously tarnishes our professional image, and more and more frequently calls into question the effects of the very things we do, is the fallacious, illogical, pseudoscientific thinking into which we have unwarily and unwisely led ourselves. I refer to that cul-de-sac, that blind alley, which for so long and so unwittingly, but so proudly, we have hailed as "clinical judgment." The scientific answer to the question "How do you know that method X is any good?" does not lie among the following: "Because that's what we were taught," or "Because so-and-so had good results with it," or "Because I see it work every time," or "Because, well, I just know it is." Beauty is in the eye of the beholder; in the matter of judging personally the effects of treatment, so too is bias.2
Mike believed in evidence-based practice long before the term was widely used. Evidence-based practice means using the best possible data to make a decision—not to justify a decision that's already been made. Unlike juries who are hopelessly deadlocked, health care practitioners have no way out when the evidence is unclear or lacking. Some would argue that evidence-based practice is punitive and causes inaction in the face of our patients' problems, but this argument reveals a lack of understanding about the almost universally accepted definitions of evidence-based practice used in other professions—or perhaps it reveals a desperate attempt to avoid the real issue.
Evidence-based practice means using the best possible evidence and recognizing that not all evidence is created equal. Sackett, Haynes, and Tugwell, pioneers of evidence-based medicine, said that the health care practitioner's role "is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."3 They have great respect for the scientific application of clinical judgment, but not the kind of "judgment" that Mike found so offensive: "External clinical evidence can inform, but can never replace individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the patient at all, and if so, how it should be integrated into a clinical decision."3 In an uncertain world, evidence is the clinician's friend—but only if the clinician takes on the challenge of practicing in a responsible manner, which includes knowing the evidence that exists (and we may be surprised just how much positive evidence exists).
Mike recognized that for many physical therapists, the profession already knew all it needed to know. For them, good practice consisted of following dogmas transmitted in professional education, continuing education, and books of dubious scientific merit. But in 1969, Mike begged us to consider the consequences:
We are guilty of depriving ourselves of the right to intellectual freedom. By jumping from hypothesis to conclusion and then applying that conclusion, while skipping all that should go on in between, we have mistaken intellectual license for intellectual freedom. Our embarrassment is compounded when we consider the intellectual despotism we impose each year on many student physical therapists....
If we wish to tyrannize ourselves and our students intellectually, that is not our own business. We have an obligation to the health care of this country, and to the people who receive it. Our obligation is to test rigorously the actions we take in the name of physical therapy.2
Mike said all this 30 years ago, before "managed cost," and before we feared our profession might be destroyed because of a lack of justifiable basis for practice. Our profession can no longer survive solely because of our belief systems. We must first truly know what is best for our patients; only then can we convince others. The first step in this long journey occurs when we know what evidence exists and when we can discuss its strengths and weaknesses.
Mike didn't accept blind advocacy. He wanted a cooperative rather than an adversarial search for evidence. I don't think that is too much to ask. What do you think?
References
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