Too Much Evidence
I finally got a chance to review the lectures from PT 2010, the APTA's annual conference. The one given by Carol Jo Tichenor particularly caught my interest. Her topic was "Clinical Experience, Patient Values Minimized by Evidence-based Movement" seemed to fly directly into the face of everything the APTA was pushing. In summary, she feels there is an imbalance in the evidence-based movement, resulting in heavy reliance on evidence while sweeping aside the value of clinical experience.
Hers in an interesting take on the subject. I don't disagree. Every course I've taken has required me to produce evidence to support my interventions. I could use clinical experience to decide which intervention but not to support my decision. My experience with the treatment could not be cited. Unless I had a study supporting my decision, the intervention was acceptable.
There are two schools of thought. One stresses the evidence over everything else. The other ignores the evidence and relies on what has worked in the past. Ideally we want a patient-focused happy medium. Somewhere along the line, clinical experience came to be looked down on because it is intangible and not always reproducible. Skill level has an effect on this. Someone who is skilled in a technique is going to have better outcomes than someone just learning it.
Physical therapy needs to stop trying to play catch-up with medicine. Medical interventions are pretty cut and dry. Either something works or it doesn't. That isn't true for physical therapy. We have a vast gray area between working and not working. If a patient fails to improve, the physician blames the patient or disease process. If a patient receiving PT doesn't improve, the treatment is at fault.
It's time to accept not everything we do can be adequately researched. There may never be evidence to support everything. NDT is a good example. There is very little research supporting the use of NDT. There is a lot of clinical experience that shows it to be an effective treatment. Does that mean I should never use NDT?
Part of clinical experience is knowing when a treatment is appropriate. Not all treatments are appropriate for all patients. Maybe the problem isn't lack of evidence but poor patient selection. The best treatment in the world will be ineffective if the wrong technique is selected. Therein lies the importance of clinical experience.
I'm glad Ms. Tichenor brought the subject up. It needs to be said. I wish I could have seen the response in the room when she spoke. She was practically supporting heresy. I hope her message is heard so we can bring some balance back to the evidence/clinical experience relationship.