Survivorship Bias and Physical Therapy

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Everyone has hopefully had a “eureka” moment in the clinic— The patient no one was able to help before, who by some stroke of genius (or more likely, luck), you are able to assist in a way that is truly remarkable. These successful outcomes are likely to stick with you. They are salient, positive and downright enjoyable to think of. Our memories of positive outcomes stay with us because most of us want to be successful clinicians. So naturally, it makes sense to try and re-create what we did, or to emulate what others did to succeed. In reality though, this does not work out so well. Continue reading

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Poking Holes in the Evidence for Acupuncture

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Throughout this entire discourse on acupuncture and needling for painful problems, Dunning et al have shown an inability or unwillingness to address central points in our argument against the effectiveness of acupuncture and needling. In addition to arriving at vastly different conclusions regarding the current trial data, Dunning and colleagues have routinely shifted the focus of the debate and presented arguments that do not relate directly to the primary issue of acupuncture’s benefits. Further, Dunning et al have consistently demonstrated a fundamental misunderstanding regarding the philosophy and implementation of evidence based practice. Their present reply is no different as they commit several critical errors in their conceptualization of evidence based practice.

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Tearing Down the Pillars of Evidence Based Practice

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One of the most common arguments stemming from our recent post on acupuncture, Needle in the Hay, was that we as a profession should not overly rely on “1/3rd of the pillars of evidence based practice”. This argument shows nothing more than a fundamental misunderstanding of what evidence based practice is. The concepts of evidence, clinical experience/expertise and patient values do not exist independently from one another. Nor can we pick and choose which of the three best suits a particular set of beliefs. In fact, we should stop referring to evidence based practice in terms of “pillars” altogether. It is an unhelpful metaphor that only serves to perpetuate a misinterpretation of the philosophy of evidence based practice. Continue reading

Why Your Expertise Does (and Does Not) Matter

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In his book The Philosophy of Evidence Based Medicine, Jeremy Howick proposes a re-defining of Evidence Based Medicine from:

Evidence-based medicine requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances

to something that better clarifies the role of clinical expertise:

Evidence Based Medicine requires clinical expertise for producing and interpreting evidence, performing clinical skills, and integrating the best research evidence with patient values and circumstances. 

This new characterization is carefully crafted to highlight the essential functions of clinical expertise while simultaneously de-valuing its evidential role. Why is such a change necessary? Because clinical expertise in isolation is unreliable in its ability to infer the benefit or harm of an intervention. The uncontrolled observations that contribute to clinical expertise is rife with confounders such as placebo effects, natural history and hasty generalizations. This is problematic when clinical expertise is assigned a significant evidential role when adequate comparative clinical studies are available. Continue reading