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Chiropractic Journal of Australia : CJA September 2013
Chiropractic Journal of Australia Volume 43 Number 3 September 2013 99 'Medicine is a science of uncertainty and an art of probability.'1 Sir William Osler INTRODUCTION In 2003 the ear, nose and throat specialist Richard Rosenthal published a commentary in which he coined the term 'uncertainty based medicine' ('UBM'). With this tongue in cheek reference to the popular term 'evidence based medicine,' Rosenthal called for acknowledgment that clinical uncertainty is an essential component of any model of contemporary health care practice.2 More recently, Jamison has noted that 'As clinical outcomes are increasingly recognized as being unpredictable, uncertainty becomes the norm in clinical care.'3 Such positions are in stark contrast to sentiments expressed in some accounts of the scope of evidence-based practice ('EBP'). For example, the mission of the British Medical Journal Evidence Centre is apparent in its internet mantra: 'Eliminating uncertainty from health care.'4 One might think that if, indeed, this was the potential of EBP, there would assumedly be no argument with the edict of Muney that '... physicians who violate its precepts should ultimately face license suspension.'5 Challenges to the concept of EBP are, however, not uncommon in health care literature, and many attempts to categorise the pitfalls in or objections to practitioners adopting EBP have been advanced. Whilst it is by no means complete, this paper offers a brief compendium of some commonly cited critiques. IMPEDIMENTS TO EBP Some accounts focus on practical impediments to EBP, eg: • EBP is too time consuming for practitioners; field practitioners do not have the time to search databases, read journals, or discuss EBP with colleagues.6-8 • Practitioners do not have the knowledge or skills to practice EBP.9 • EBM creates more work in an already hectic vocational practice environment.10 • EBP might expose practitioners to legal action if it is determined that therapies previously undertaken were ineffective or experimental. • There may be fnancial ramifcations to EBP. A striking example of this was the attempt to subject radical keratotomy (an operation to correct short sightedness) to a randomised controlled trial ('RCT') in the United States. The researchers were blocked by ophthalmologists who faced a loss of income if the procedure was declared 'experimental' because it would mean health insurance companies would no longer reimburse them. As a result of legal action, the researchers were forced to declare the operation safe and effective and abandon any attempt at evaluation.11 Others writers have examined and criticised the political dimensions of EBP, with some holding that EBP reduces practitioners' autonomy: • Decisions based on patient care can be taken out of the hands of practitioners and placed in those of managers and bureaucrats who know nothing of the actual practice of health care, let alone the individual patient in question.12 • EBP only serves the cottage industry of those producing EBP guidelines.13 The explosion of the EBP industry with its focus on implementation has essentially removed the basic assumptions of EBP from scrutiny. THE PROBLEM OF UNCERTAINTY Many other challenges to EBP introduce and imbue the notion of uncertainty. This is often manifest as it concerns the inability and inadequacy of formal research methodologies, which are intrinsic to many accounts of EBP, to provide a suffciently robust epistemology upon which to base health care practice. Some objections fnd their basis in classical protestations to the positivism proposed by philosophers of science. • The Problem of Induction Chiropractors have been exposed to Bertrand Russell's inductivist turkey by Charlton.14 Prosaically, this equates with the position that whilst there may be certainty in what has occurred prior, there can never be certainty in what will occur in the future. An example of how this pertains to health care practice is to state that whilst we may observe that a particular number of patients may not have benefted from a therapy, it is logically impossible to predict with 100% certainty that the next person will not.15 • Underdetermination There is an infinite number of possible theoretical explanations to account for any particular empirical observation. Scientific theories are therefore 'under' determined, as any number of explanations may plausibly account for an observation. Our allegiance to any particular theory to explain a set of results is not determined by nature alone. Our conclusion that the cause of low back pain can be explained in terms of altered biomechanics may be just as plausibly explained by reference to alterations in vascular supply. In this sense allegiance to one particular theory to account for an observation is illogical.16 • Theory Ladenness and Social Constructivism According to this stream of analysis, it is impossible for a scientist or any observer to make a neutral empirical observation. All conclusions and assumptions we make are grounded in our previous experiences, which will Commentary: Clinical Uncertainty BARRY DRAPER and DENNIS RICHARDS
CJA June 2013
CJA December 2013