An opinion piece to restart my blogging after my lovely holiday…
I’ve been reading ABC Therapeutics blog where Chris Alterio writes in response to a long comment by Michele Karnes suggesting that occupational therapists (and by inference all health care providers) ‘should be made aware of treatments that are offered to clients/patients, whether it is traditional or non-traditional, a long existing treatment or new one. This enables our OT profession and professionals to better educate the people they treat and interact with.’
I don’t have any particular concerns about this part of Michele’s comment – but I do have a problem with this part ‘while Evidence Based Practice is on all of our minds, and ultimately the best to utilize with our patients, if we only used treatments for all of these years we would have missed out on the many treatments that OT’s have historically (and still) use.’ (my emphasis)
It raises some concerning things for me – and while I don’t have answers for all of my concerns, I hope to stimulate some debate at least.
Chris writes in his blog ‘Just because people seek out alternative energy healing interventions doesn’t mean that it constitutes appropriate or ethical practice. In an article published in the Journal of the American Medical Association on this topic an author writes: “Given the extensive use of CAM services and the relative paucity of data concerning safety, patients may be putting themselves at risk by their use of these treatments. Only fully competent and licensed practitioners can help patients avoid such inappropriate use... Physicians can also ensure that patients do not abandon effective care and alert them to signs of possible fraud or danger.“‘
I’d add that licensing in itself does not inevitably lead to patients being helped to avoid inappropriate treatments. I also add this:
I think it also takes a critical and educated mind, a systematic approach to reviewing evidence, and considerable determination not to be swayed by forceful opinion.
Evidence based practice has been lauded as the best approach to finding appropriate treatment for patients, but at the same time has been criticised for failing patients because researched studies are inconclusive; contradictory; don’t exactly match the unique presentation of the individual in front of the health care provider and/or lag behind ‘real’ practice because of the focus on randomised controlled trials. Probably there are a few other reasons others have come up with too!
As far back as May 1997, Dr Nicholas Hicks from the Department of Public Health and Health Policy, Oxfordshire Health Authority, UK defined evidence based health care as ‘when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.” He further discusses this definition on this page in Bandolier. I take this to mean that health providers have the freedom to be innovative and try new approaches provided that they are constrained by valid and relevant information.
What this means to me is that any new treatment should have a sound theory-base and that it has been demonstrated in some form to be effective in a similar situation. I think it’s OK to generalise, for example, exposure-based therapy for kinesiophobia because it has very strong evidence from other conditions where avoidance serves to reinforce the anxiety state, eg spider phobia, social phobia.
Where a treatment really is brand new, let’s think of mirror therapy, laterality training or motor imagery training for CRPS for example, the patients need to be fully informed of the experimental status of the intervention, any potential ill-effects from treatment, and be informed about alternative interventions and the level of evidence for them. Then they can make an informed decision.
Where things start to get unravelled for me is when a treatment implores us to look beyond conventional scientific knowledge and into mysticism, magical thinking or ‘alternative’ energy, aura, vibrations or whatever. I don’t mean to throw the baby out with the bathwater, I hasten to say, because I’m fully aware there are many things we simply don’t know about in the universe because we don’t have technology to measure them – but the absence of a testable hypothesis means we are required to believe, trust or otherwise suspend critical thinking, and I’m a scientist not an artist!
Even if a treatment did draw on ‘alternative’ dimensions, our patients live in a world where real pain, real disease and real suffering exist. If an ‘alternative’ treatment is not able to demonstrate change that is more than placebo in this real world, then it is simply unhelpful at best, and wasteful or even destructive at worst. We ask no less of conventional health care, why would we ask less of ‘alternative’ interventions?
The upshot of this situation is this: if we are innovative and come up with a fantastic new treatment that we are convinced ‘works’ – we need to be prepared to submit it to a structured and systematic analysis of its effect, making allowances for all the usual confounds that make identifying effects so challenging.
That means in the main, carefully and systematically manipulating each variable in a treatment to be sure that the only factor involved in the effect is that one we think it is. This is hard work! And most of us as clinicians simply don’t have the time to do this in our everyday practise. And it’s not OK to appeal to the idea that we are somehow denying our patients something important because we can’t use our new improved treatment – because in the absence of evidence, our opinion is that – opinion, conviction, belief, faith.
One of the problems with occupational therapy specifically is the lack of hard evidence to support the ‘many treatments that OT’s have historically (and still) use.’ Sad to say, I don’t find evidence for (or against for that matter) many of the treatments used by occupational therapists. Some of the mainstay treatments I was trained to use such as static splinting for acute rheumatoid arthritis and ‘ergonomic equipment’ for low back pain (even ‘safe manual handling’ to protect from acute low back pain) are no longer supported. Other interventions such as activity scheduling or time-based activity planning have received increasing support – but not from the occupational therapy literature.
It is time to increase the awareness of all health professionals, not just occupational therapists, of the need to develop and actively use critical thinking to make decisions about treatments that should be used. This doesn’t just mean training our newer members of the professions during their training, but more importantly, seriously addressing the knowledge shortcomings of our more senior members of the professions. For a brief summary of this, head to Bandolier again.
These are the people making important decisions about what treatments should be used, which treatments should be funded, and ensuring health professionals within organisations are given adequate time to do the ongoing learning and reviewing of the literature that is essential. It’s health managers who decide how therapist time is spent, and the current focus on face-to-face time with patients as the only aspect of treatment delivery that is counted means that therapists don’t get adequate time to develop or review their treatments. But that is another post!
How can I, as a health professional with a science background, influence these senior clinicians? There is no single way, but two immediately come to mind
- Ask questions about treatment effectiveness. Does it work? Who does it work for? How do we know it works? Is it the most effective way to treat this person? And do something about measuring and writing about outcomes.
- Publicise the need to be a critical thinker (and show them how). I do this by blogging, but it’s not the only way. Conducting peer reviews, reviewing our own practice and talking about it, taking inservice education, facilitating a discussion, letters to the editor, completing quality forms – all of these are steps we can take to raise awareness that “Evidence based health care takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.”