There are some people who are afraid of evidence based care. It’s beyond me to explain why.
What’s not to like? Unless of course the evidence points away from what you would like to believe. In that case, accept it and move on.
That doesn’t mean that you need bullet proof RCT evidence to treat someone in a particular way. It does mean that the evidence at least guides you in your thinking. Anything else makes the treatment “experimental”, and should be conducted as practice based research.
“Evidence-based medicine is not “cook-book” medicine. Because it requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patient-choice, it cannot result in slavish, cook-book approaches to individual patient care. 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 individual patient at all and, if so, how it should be integrated into a clinical decision”. Source: Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312 (7023), 13 January, 71-72
Hi Richard,
Some chiropractors like myself do not like evidence being presented the way sceptics do as some kind of truth that can be applied universally to all people, as one evaluates drugs using quantitive studies. Because the chiropractic intervention requires great skill as well as knowledge and varies widely from practitioner to practitioner, qualitive studies are a more appropriate way to investigate an Art like chiropractic. Since the BCA rejected the “ACC paradigm” they have presented evidence in the sceptic manner to the UK profession and why they came unstuck with Simon Singh.
BCA president Richard Brown presented his “plethora of evidence” as an answer to Simon Singhs question and of course everybody laughed at him. The media see evidence as true or false. Having debated with the sceptics for years on my blog I can say they know little of Sackett and a lot of Ernsts narrow interpretation of scientific evidence.
They criticise chiropractors for using of case studies, then use case studies to say chiropractic causes stroke, when there is not a “jot” of evidence showing a causal relationship. The “evidence” debate should have been presented as Sackett intended a hierarchy of the “best evidence available” combined with clinical experience . The BCA should have responded in that manner to Simon Singhs original article in the Guardian.
The profession has been brought to its knees because Tony Medcalfe told members not to worry, “None of my patients have heard of Simon Singh”. The profession was not prepared for this the BCA council acted unilaterally and reduced AECC graduates to the level of homeopaths. Will the phoenix rise from these ashes with Richard Brown at the helm?
PS Meerseman does not use drugs for AC Milan players. Thats why he says they can play until they are 40.
By: Richard Lanigan on April 16, 2010
at 10:56 am
Hi Richard
It seems we agree on what evidence informed care means. There are some that would have it that EBC says that if there is no positive RCT for a treatment then there is not enough proof for clinical practice.
One of the things I am trying to demonstrate is that this is not what is intended at all. It’s an application of the best available evidence with clinical experience and patient preference.
Quantitative studies are not suitable for every intervention, but RCT’s are still at the top of the heirarchy of evidence. If there is none for a particular treatment or if it is not suited to RCT’s, then you go to the next level down. But I don’t have to tell you that.
According to Haldeman’s commentary on the Bronfort trial 90% of daily chiropractic practice is now supported by good evidence. That’s better than any medical field if you take Ben Goldacre’s figures.
To progress in the UK I think chiropractors must do what the Danes decided in the early 1990′s and focus on chiropractic management of MSK problems, particularly of the spine ie what there is evidence for.
They do seem to still use medication at AC Milan. Meerseman has spoken of the reduction of non-impact injuries at Milan since he took over, and that they now use far less steroid injections than before. They still use them though. I also remember Maldidi had 3 painkilling injections before the 2007 Champions League final to his knee. Meerseman does not prescribe them himself of course, presumably the club doctor does.
Btw, and I hope this will make you laugh, AC Milan are sponsored for 2010-11 by the anti-inflammatory drug Liotondol…..
By: Richard Hollis on April 16, 2010
at 2:40 pm
I did not know that, thats what he said in an interview in the Guardian. I would not dissagree our meal ticket in terms of evidence is MSK. Its not just because of the evidence, its because we are good at it and experienced. The Danes fund chiropractic for colic. Personally I think the profession should focus on why a spinal adjustment is effective at reducing pain and establish the relationship with the CNS. Then you could get everyone on the same page and the profession would be in a better position to defend themselves. Simon Singh had a baby recently and announced it on twitter saying if the child had colic he would not take him to a chiropractor.
I e-mailed him explaining why chiropractic might help a child with colic. Then I asked him looking at the “best evidence” what would he do to help his child if he had colic. I dont think he has been able to find anything else.
You need a few hundred chiropractors to start blogging and link their blogs together to push them up SEOs, but you need leadership.
I suspect the BCA think this is the end of the matter, mark my words this is the beginning not the end, the sceptics have the wind in their sails and this is how they entertain themselves.
By: Richard Lanigan on April 18, 2010
at 9:38 pm