Clinical Pillar – Program Overview – Apprentice
William J Owens Jr DC DAAMLP CPC
“If you do NOT have a plan, you are part of someone else’s” – Terrance McKenna
Chiropractic and Clinical Practice Guidelines
Since the National Spine Management Group is about working with the medical community and promoting the “evidence” that supports chiropractic, I wanted to review an article that was published in help to lay a foundation for you to not only understand the weaknesses of many of the CPG arguments, but will hopefully also energize you to engage medical professionals at the community level.
In the abstract portion of the paper, the authors state, “When focusing on generating evidence, a major barrier to the rapid passage of research into clinical practice is that the ‘practice’ in trials or research settings could be a long way from the setting, circumstances, patient groups and resources available in the daily practice of many clinicians” (Ostelo et al., 2010, p. 281). This is interesting since the entire idea of “evidence-based practice” is to take the “evidence” and put it into practice. What the authors are saying is that unless the process in the trial takes into consideration the randomization of the patient populations that we see (We don’t select our patients, they select us!), the results of the trials that are being introduced into CPG may be inaccurate. The people that are selected for the trials are done so based on the “choices” that the researchers make. In other words, the participants are selected to be part of the study based on specific criteria. In a controlled research environment, that is important, but it does not necessarily translate into the clinical setting. In the clinical setting, patients that are diagnosed with lower back pain may have a multitude of causes and co-morbid factors that affect the outcomes. Therefore, there can be a tremendous disparity between the research setting and the clinical environment. The authors report, “A recent systemic review assessing the eligibility criteria of RCTs [randomized controlled trials], published in high-impact medical journals, concluded that exclusion criteria [why people were NOT selected] were not always clearly reported. Moreover, women, children and elderly and those with common medical conditions are frequently from RCTs” (Ostelo et al., 2010, p. 283). The problem with not reporting the population that was “excluded” is a major issue and one of the many reasons that research is not easily translated into clinical practice and certainly why many CPGs are not accurate for the long haul.
Additionally they state “For LBP [low back pain] RCTs, in addition to these subgroups, patients with previous back surgeries and co-morbidities are regularly excluded” (Ostelo et al., 2010, p. 283)
How does this information translate into daily practice and your ability to use this information to build relationships and MAKE MORE MONEY? Here is the golden egg from this paper and the ONE thing that can be the basis for everything you do…“A survey of GP [general practitioners] revealed that most did not understand the fundamental terms used in EBM [evidenced-based medicine]…” (Ostelo et al., 2010, p. 285). They also went on to say that busy clinicians need a resource to help share important EBM information. That is where we come in and that is why this entire process is effective both in the short and long term. Each piece of research that is presented is part of the larger clinical picture. Teaching the MD about how care should be directed and establishing yourself as a resource is what will take chiropractic to a 95% utilization rate.
When you are teaching MDs about the basic tenants of chiropractic, understand that most clinicians feel that CPG do not accurately represent the populations they serve. The authors agree with that statement by reporting, “The problem with adoption [of CPG] was that the practitioners felt they were faced with more complex problems in daily practice than was assumed in the guidelines; that the patients’ priorities might not coincide with those assumed by the guideline, and that there was a tension between the standardization of care required by the guidelines and the individualization of their problem often required by patients consulting with back pain” (Ostelo et al., 2010, p. 287).
Therefore, your position is to help fill the need of the MD and that need is how to handle individual complex issues in his/her practice. We start with musculoskeletal problems and then work our way up to asthma, colic and inner ear infections.
MDs do not need more guidelines; what they need is you!