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Chiropractic Journal of Australia : CJA September 2013
Chiropractic Journal of Australia Volume 43 Number 3 September 2013 101 • Our management choice and likely effcacy, the patient’s response and prognosis and our own knowledge, expertise, skills, motivation and competence. 'In complex systems, unpredictability and paradox are ever present, and some things will remain unknowable.'40 Rather than sweeping it under the carpet, we should embrace uncertainty as simply part of what we do. Accepting that uncertainty exists differs from succumbing to or preferring ignorance. We do not propose that practitioners should not seek to inform themselves. Like Rosenthal, we do not contend ignorance to be preferable to knowledge, but rather for our perception of knowledge to be as dynamic, not static or set in stone.2 There are several benefts to this. Firstly, it means that we can approach each and every clinical encounter, from one patient to the next, with the knowledge that things may differ. This teaches us that our assessment and management must be entirely iterative - subject to review, to reconsideration, to interpretation, to exposure to new or changing information. As Chalmers places this, 'Whatever the basis for judgments about the likely effects of treatments in individual patients, there is no escape from the reality that every such judgment initiates a clinical trial in which there can be no certainty that an individual patient will beneft.’41 Uncertainty fuels critical refection about our activities. Did the patient improve because of our intervention alone, natural history or placebo or what combination? Unrefective belief in our apparent successes can lead to complacency and overconfdence, resulting in an unwillingness to consider alternatives, rendering us more susceptible to error and to persisting with strategies that may be less benefcial than others.42 We owe it to our patients to achieve the same outcomes with less rather than more. Uncertainty induces an epistemological humility that undermines self-congratulation when Mother Nature may well have done all of the work. An appreciation of uncertainty forces us to expand any stifing interpretation of what EBP really is, allowing us to take on face value the commonly-used description of evidence- based practice in medicine as requiring '... the integration of the best research evidence with our clinical expertise and our patient's unique values and circumstances.'43 In the light that no one information source is unquestioningly privileged or infallible we may now openly acknowledge that practitioners have since the dawn of healing and will continue to draw upon various sources to inform their practice. Factors such as our own clinical experience, the collective knowledge of our herd or practitioner group and even intangibles such as a gut feeling do inform clinical practice and must be granted voice.44 This reality, too often ridiculed as unsophisticated or anachronistic, allows us to admit to the fact that all of us at the coalface of vocational practice learn as much from our own mistakes or talking with colleagues as we do from databases and journals. The retreat from scientism and positivism such an approach imbues also encourages a more humanistic model of practitioner-patient interaction. In over-emphasising the signifcance of knowledge generated by formal research methodologies above the word of a patient, an imbalance is set up in the relationship. Uncertainty exposes the myth of the impartial, all-knowing practitioner and facilitates a shift towards a model that sees a practitioner truly willing to listen to and learn from their patient through interaction and negotiation. Listening to a mother's view of what is ailing her child becomes an imperative and not an option to be exploited as to appear politically correct. The political and medico-legal benefts to this approach are also self-evident. Freed from the dangerous consequences of believing we are always right, practitioners are more inclined to be circumspective when explaining to patients diagnostic possibilities or potential outcomes of intervention. Early and prudent elucidation of possible adverse outcomes is a most sensible step in minimizing liability. This should not be seen as compromising the expertise of the practitioner but rather an unavoidable product of the humanity of the health care encounter. CONCLUSION In 2001 McNeil argued that the major hidden barriers to better health care are due to a lack of discussion of the impact of uncertainty in medicine.'45 Ludemer has cited the failure to train doctors about clinical uncertainty as 'the greatest defciency of medical education throughout the twentieth century.'46 We contend all models of health care education and practice, including chiropractic, must be conducted with this defciency in mind. Barry Draper BAppSc, MSc. Head, Discipline of Chiropractic, RMIT University, Bundoora, Vic. Dennis Richards, BSc, DC, Grad Cert Phil Studies, ACP, FACC, FICC. Private Practice of Chiropractic. Tweed Heads, NSW. REFERENCES 1. Ac c e s s ed at: http://www.brainyquote.com/quotes/quotes/w/ williamosl159326.html 2. Rosenthal R. UBM. Uncertainty based medicine. Otolaryngol Head Neck Surg 2003;128(1):5-7. 3. Jamison J, Hawk C. Patient education and wellness. Edinburgh: Churchill Livingstone Elsevier; 2010. p. 47. 4. Accessed at: http://group.bmj.com/products/evidencecentre/BMJ%20 Evidence%20Centre_brochure_1108.pdf 5. Muney AM. Evidence-based medicine needs to be promoted more vigorously. Managed Care 2002;11(2):10-2. 6. Callen JL, Fennell K, McIntosh JH. Attitudes to, and use of, evidence- based medicine in two Sydney divisions of general practice. Aust J Primary Health 2006;12(1):40-6. 7. Askew DA, Clavarino AM, Glasziou PP, Del Mar C. General practice research: attitudes and involvement of Queensland general practition- ers. Med J Aust 2002;177:74-7. 8. Bennett S, Tooth L, McKenna K, Rodger S, Strong J, Ziviani J, Mickan S, Gibson L. Perceptions of evidence-based practice: A survey of Australian occupational therapists. Aust Occup Ther J 2001;50:13- 22. 9. Oliveri RS, Gluud C, Wille-Jørgensen PA. Hospital doctors’ self-rated skills in and use of evidence-based medicine -- a questionnaire survey. J Evaluation Clin Pract 2004;10(2):219-26. 10. Heiwe S, Kajermo KN, Tyni-Lenné R, Guidetti S, Samuelsson M, Andersson IL, Wengström Y. Evidence based practice: attitudes, knowledge and behaviour among allied health care professionals. Int J Quality in Health Care 2011;23(2):198-209. 11. Norman C. Clinical trial stirs legal battles. Science 1985 Mar 15;227(4692):1316-8. CLINICAL UNCERTAINTY DRAPER • RICHARDS
CJA June 2013
CJA December 2013