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Chiropractic Journal of Australia : CJA September 2013
100 Chiropractic Journal of Australia Volume 43 Number 3 September 2013 differ from one person to the next. Completely unbiased conclusions about, for example, the effcacy or lack of, of a particular therapeutic modality cannot occur.17,18 Scientists are equally as prone to infuence, to irrationality, to prejudice, as any other human being. All knowledge is therefore constructed, not certain and subject to interpretation and to change.19,20 A telling example of the subjectivity of scientifc method is evident in the manner in which scientifc reports are constructed. The inherently human and political nature of statements such as 'is no better than' or 'is as effective as' in interpreting the same data set is an exemplar. Expert and peer review panels, which are mechanisms proposed to 'police' the expression of scientifc results, are comprised of human beings, subject to all of the foibles of human beings, i.e. subject to infuence or holding various levels of competence. • Standards? The rules and standards utilized in statistical analysis are therefore also social constructions. On what basis are abstract determinations such as the 'need to treat' established? What determines a particular numerical fgure to be ‘statistically signifcant’? How many trials, systematic reviews or Cochrane reviews does it take to determine what is true and what is not and whether a particular treatment should be endorsed or abandoned?21 RCTs are expensive and they often receive the fnancial support of groups who may have a vested interest in the outcome of the trial, rendering the results subject to inappropriate infuence or sway.22 PRAGMATIC REALITIES Other objections which imbue the notion of uncertainty are somewhat more pragmatic. Some modalities are impossible to investigate using double-blinded RCTs, the so-called 'gold standard' of evidence. Whilst double blinding may be possible when investigating the use of, for example, pharmaceutical agents, it is impossible to blind activities that involve more decisive practitioner involvement, such as manual therapy or surgery.23 EBP does not capture the crucial role of tacit processes in clinical practice.24 Knowledge acquired from formal research activities is always incomplete. Knowledge and skills derived from hands on exposure, from experience and practice are unquestionably required in order to fully apprehend clinical practice.25,26 RCTs seek to maximise participant homogeneity and accordingly seek to hide from view the number of variables impacting upon the lives of participants. But life is not like this. The etiology of wellbeing, health and disease is multifactorial and complex. Such a reductionist perspective provides a limited understanding of clinical practice.27 Formal research activities cannot be used to account for medical knowledge derived from the basic sciences or on the basis of biological plausibility, yet much of medical practice relies on knowledge generated by such referents.28,29 The fndings of formal research activity, which EBP prioritises, are often limited to the evaluation of the effcacy of singular procedures eg a particular drug. Yet patients often require multiple forms of management with effects being linked and cumulative.30 Formal research activities tell us little about the origin/s of disease and thus offer little insight in terms of prevention. Understanding why the patient became ill in the frst place may not be suitable to this type of episteme.31 Trials are generally acknowledged as unnecessary in some circumstances, for example when the potential outcome is dramatic eg anaesthesia for a fractured femur; we rely on practitioner experience to inform us as to the worth of such intervention.32 Where, however, is the dividing line separating interventions for which practitioner experience is considered as acceptable evidence and where it is not?33 There is a paucity of formal research evidence in some areas. If practitioners are to look to research evidence to guide their practice, how are they to deal with care in which little or no research has been done? The notion that EBP provides better care or better patient outcomes has also been brought into question. Proponents tell us EBP proves better outcomes, but where is the proof of this? Where is the evidence?34-36 DISCUSSION So where does this leave us? The defnition of EBP can be confusing, and we readily agree with Parker that descriptions as to the metaphysical basis and epistemological scope of EBP are on a spectrum.37 Whether EBP is, however, presented as a process or a philosophy, whether the practice of EBP equates with the uncritical acceptance of RCTs and denigration or rejection of all other forms of evidence, or involves the integration of practitioner and patient experience with formal research fndings, or whether EBP is considered the panacea to all our ills or a fash in the pan, we argue that the conclusion that the health care encounter is peppered with unavoidable intangibles is both inexorable and must not be hidden from view. In clinical practice and in the training of our practitioners, clinical and methodological uncertainty must not be presented as an unacceptable impediment to be overcome, or as a troublesome reverse salient. We have an obligation to our patients to continually review and, when needed, refne what it is that we do.38 In embedding the notion of uncertainty into our undertakings, we are liberated from the unfalsifable stance of those who hold that a priori assumptions about chiropractic represent a suffcient and justifable platform upon which to practice; that chiropractic is self evident and in no need of ongoing evaluation and review. But we are also liberated from the absurdity of the belief that certainty can and should be our objective at all costs. Uncertainty in health care is intrinsic and inescapable. As Paul et al place this: 'Uncertainty pervades and motivates every activity related to health care.'39 In addition to its presence in our research paradigms, uncertainty is characteristic in the vocational practice of chiropractic across such elements as: • Our patients' perceptions of their bodies, their ailments, their motivations, desires, and needs for seeking care. • The etiology, predisposing and contributing factors of and co-morbidities associated with patients' maladies. • Our diagnosis and ordering of differentials, the validity of our procedures and interpretation of our results. CLINICAL UNCERTAINTY DRAPER • RICHARDS
CJA June 2013
CJA December 2013