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The “Nuts and Bolts” of Evidence-Based Physiatry

Core Competencies for Trainees and Clinicians

Rizzo, John-Ross MD, MS; Paganoni, Sabrina MD, PhD; Annaswamy, Thiru M. MD, MA

American Journal of Physical Medicine & Rehabilitation: October 2019 - Volume 98 - Issue 10 - p 942–943
doi: 10.1097/PHM.0000000000001269
Evidence-Based Physiatry
Free

From the Department of Rehabilitation Medicine, New York University Langone Health, New York City, New York (JRR); Department of Neurology, New York University Langone Health, New York City, New York (JRR); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts (SP); Physical Medicine and Rehabilitation, UTSW Medical Center, Dallas, Texas (TMA); and Physical Medicine and Rehabilitation Service, VA North Texas Health Care System, Dallas, Texas (TMA).

All correspondence should be addressed to: Thiru M. Annaswamy, MD, MA, VA North Texas Health Care System, 4500 South Lancaster Rd, #117, Dallas, TX 75216.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Online date: July 23, 2019

Evidence-based physiatry (EBP)1 is the efficient integration of the following:

  1. best available external research evidence,
  2. the patient’s unique values and expectations, and
  3. the practitioner’s clinical expertise and skills as they relate to the practice of physiatry.

The primary objective of this article is to provide a basic framework for the integration of EBP into:

  1. training programs in physiatry and
  2. daily clinical routine.

Despite the availability of several teaching approaches, incomplete comprehension of EBP principles may be a major barrier to its incorporation into clinical practice. One significant impediment is the inconsistency in EBP teaching standards and residency programs that are more focused on clinical training. Therefore, creating a best practices approach to these concepts is a first step toward the standardization process of EBP training, ultimately facilitating lifelong EBP adoption.

A recent consensus statement on the core competencies of evidence-based practice delineated five critical steps as foundational elements that could be applied to physiatry.2

The five steps include the process of asking, acquiring, appraising/interpreting, applying, and evaluating.

Step 1: Ask – An ideal EBP curriculum starts with the process of “asking”: asking meaningful questions, asking different types of clinical questions, and a focus on the rationale behind structured “asking.”

Step 2: Acquire – Next, comes the process of acquisition. Presently, clinical evidence can be swiftly reviewed using the Internet search engines and platforms, such as PubMed, Medline, EBSCO host, etc. There are two basic strategies to retrieve information. The “push” strategy alerts the user to new information. This can also be described as “just-in-case” learning. Pre-set search terms can be used to populate clinical research platforms, and important, new, valid research that the user is interested in can be “pushed” to the user’s screen as and when such information becomes available. The “pull” strategy is useful to access information when needed, such as at the point of care. This “just-in-time” learning helps the user formulate and refine the research question originally “asked,” setting the baseline for next steps.

Step 3: Appraise and Interpret – This step requires at least basic knowledge of statistics (e.g., bias, reliability, validity, difference between statistical significance, and minimal clinically important difference), different study design types (e.g., systematic review, meta-analysis, controlled trial, observational study), and levels of evidence. By selectively searching for articles with high levels of evidence (randomized trials and systematic reviews), a user can identify preappraised evidence-based information in a more discerning manner (expediting the “appraising” process). This selective searching of literature, specific to the clinical questions being asked at the point of care, enables the user to not only better “catch up” with contemporary information but also access and efficiently apply evidence-based information to clinical care.

It is also important for the learner to be able to distinguish evidence-based from opinion-based clinical practice guidelines and recognize the importance of considering conflict of interest and funding sources.

Step 4: Apply – Refining and standardizing a well-defined process to access and apply “best research evidence” in relevant clinical scenarios create a clear intersection/step by which the external evidence thus retrieved and synthesized is blended with the user’s own clinical expertise and the reflections from the patient (expectations and values). Thus applied, EBP becomes less of a burden and more of a natural mainstream application of evidence-based medicine principles in routine clinical practice. Once this process is practiced and protocolized, the clinician can better balance the continuously expanding volume of medical knowledge and apply this information to improve health care.

Additional core strategies that may help the incorporation of EBP into clinical practice include the following: engaging patients in the decision-making process, structuring management approaches to mitigate uncertainty, explaining baseline risk thoroughly when estimating expected benefits, and elucidating the grading of certainty in evidence and in health care recommendations.

Step 5: Evaluate - The last step in this progression is the process of evaluation. Evaluation is crucial to the cyclical and iterative nature of this process. Self-reflection and evaluation of the EBP process includes the incorporation of techniques to recognize barriers to EBP adoption at the clinician level, creating the opportunity for tailored change, to foster reflective clinical practice approaches, and to encourage personal auditing with regard to performance outcomes.

The alternative to EBP is status quo physiatry, which involves the provision of clinical care to patients based predominantly on increasingly outdated training from years past. This traditional model excels in building a solid foundation of medical knowledge and expertise but does not allow for systematically introducing new evidence into the patient care paradigm. By implementing an EBP approach to clinical care, the user combines solid clinical expertise with evolving external evidence. The clinical decisions and opinions thus formed are more reproducible and bias free and allow the clinician to more easily accept and adapt new evidence. The result of the process helps systematically improve patient outcomes.

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CONCLUSIONS

Evidence-based physiatry principles are important to understand and should be taught in residency programs following well-defined teaching approaches. By following a structured framework for the integration of EBP into their clinical routine, clinicians can successfully move toward an evidence-based practice, driving outcomes and patient satisfaction forward in their daily clinical care.

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REFERENCES

1. Frontera WR: Evidence-based physiatry and social media: two new sections. Am J Phys Med Rehabil 2018;97:465–6
2. Albarqouni L, Hoffmann T, Straus S, et al: Core competencies in evidence-based practice for health professionals: consensus statement based on a systematic review and Delphi survey. JAMA Netw Open 2018;1:e180281
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