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How are we doing? Arguments for Practice-Based Evidence
In past years there have been increasing calls for evidence based practice (EBP) in the fields of medicine, psychology, social work, nursing, and many other healthcare professions¹. If calls for EBP have spanned the breadth of healthcare, so too have the arguments against it. Clinicians often perceive researchers as out of touch with the realities and nuances of clinical practice, unsympathetic to the human dimensions of clinical care, disrespectful of the value and importance of clinical judgment, and often as just plain arrogant. Clinical researchers often perceive practitioners as underinformed and in need of guidance from the empirical evidence base. It might seem that EBP would only aggravate these tensions. But I suspect there may also be opportunities here to create bridges that will permit understanding across the research-practice divide.
One such possibility is to begin building practice-based research. While we argue that EBP can improve outcomes, we really do not even know how well behavioral medicine practitioners are doing. To the best of my knowledge, there are very few data on effectiveness of behavioral medicine clinical practice. For psychological disorders in adults, analyses of one data set of more than 6000 patients treated in HMOs, community mental health centers, employee assistance programs, and university health clinics, found that 8% deteriorated, 57% showed no reliable change, 21% showed some reliable change (not necessarily a clinically meaningful change), and only 14% met criteria for recovery². While this suggests that outcomes in practice are fairly dismal, the study has many flaws. The characteristics of this sample and study are not clear, it is not clear which problems were treated, by whom or how.
A critical step at this point is to develop practice-based evidence that would improve our understanding of outcomes in real clinical practice. This information is required for at least four reasons. First, an understanding of practice based outcomes is essential for understanding the state of our field. We may be providing reasonably effective care, or we may be providing care that is far less effective than we think. And likely there are specific areas of successful practice and areas of practice that require added attention.
Second, timely collection of practice-based outcomes could improve outcomes. The success or failure of many ailments treated in primary care are monitored by independent or objective evaluation. Treatments for hypertension are monitored with routine checks of blood pressure. Treatments for high cholesterol are monitored with blood labs. While some of the targets of intervention by behavioral medicine specialists can be routinely checked, such as weight, others such as depression, pain, or fatigue are not generally monitored objectively. A growing body of work indicates that providing clinicians with objective feedback on the targets of treatment can improve outcomes³.
Third, practice-based evidence could begin to teach us what works in clinical practice versus what does not. It is likely that some clinicians are better than others. Some groups may be better than others. Identifying and understanding these differences may begin to help us understand what works and what does not.
Finally, practice-based evidence can provide us with the critical information regarding the adequacy and effect of instituting evidence based practice. Without feedback from systems in which EBP is implemented, we have no way of knowing if EBP is being properly implemented or having the desired effects.
A wise clinical supervisor of mine many years ago said "assess, assess, assess, assess before you intervene, while you intervene and assess after you intervene." The EBP movement has high goals and aims. But it is critical that we develop the capacity to assess the system we are trying to treat. We cannot have evidence-based practice without first having good practice-based evidence.
As always, I welcome your thoughts, ideas and feedback. Feel free to write at email@example.com.