Critical Thinking

Evidence-Based Practice: A Proposal for an updated definition of Clinical Expertise

Back in the mid-90’s, Dr. David Sackett introduced a model for evidence-based practice (EBP) which was defined as ““the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

His model was built upon the integration of three variables:

  1. Best Research Evidence
  2. Clinical Expertise
  3. Patient Values and Preferences

While these 3 variables were identified as being key ingredients to EBP, I am disconcerted by the amount of weight many have given to #2 when discussing their own models of clinical practice. When Sackett defined this model, what did he really mean when he said “Clinical Expertise”?   I went to some of Dr. Sackett’s original work to attempt to understand.

From a 1992 paper on this topic, Dr. Sackett stated:

” Clinical experience and the development of clinical instincts (particularly with respect to diagnosis) are a crucial and necessary part of becoming a competent physician. Many aspects of clinical practice cannot, or will not, ever be adequately tested. Clinical experience and its lessons are particularly important in these situations. At the same time, systematic attempts to record observations in a reproducible and unbiased fashion markedly increase the confidence one can have in knowledge about patient prognosis, the value of diagnostic tests, and the efficacy of treatment.

In the absence of systematic observation one must be cautious in the interpretation of information derived from clinical experience and intuition, for it may at times be misleading.”

In another paper, he described clinical expertise as:

By individual clinical expertise, we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.  Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.”

While attempting to disseminate Dr. Sackett’s thoughts on this subject,  I began to suspect we need to update the entire model.  While clinical experience is important in improving professional confidence, I am not fully convinced it equates to 1/3 of the model. I actually suspect it leads to cognitive dissonance when the experienced provider is challenged with evidence which is contradictory to their current practice.

It actually appears that his integration of clinical expertise into the early EBP model was a political way to say, “Hey you older docs are doing some ok stuff.  But use your expertise in combination with the evolving evidence.”  This appears evident when he states, “Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.”  Experience is not alone a measure of expertise (this argument actually leads to a genetic fallacy).

Below I have proposed a new provisional model of EBP, utilizing Sackett’s work in combination with my best understanding of current practice.

My Proposed Model of EBP:

  1. Best Research Evidence
  2. Patient Values and Preferences
  3. Clinical Expertise as defined as:  a. Practice built upon clinical reasoning development through measures of introspection, cognition and metacognition (this may be through formal post-graduate residency, fellowship or other formal mentoring opportunities.  This will allow for peer-review of your ability to truly reason through clinical work).  b. Practice built upon a model of critical thinking that is scientifically defensible and plausible

I propose clinical expertise is not simply gained through practice.  It is built through assessment of your ability to think, reason and apply scientifically plausible principles into practice.   It requires peer-review.  It requires your thoughts and ideas to be challenged.  It requires a hint of uncertainty.

What do you think?  I would love to hear from you guys, and if we can begin to integrate some of these concepts into action!

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15 replies »

      • I could get behind this model as well. Despite the term “experience” being used (again, I am not sure how experience can improve expertise if the experience goes unchallenged), they carefully address this concept as being multi-faceted and patient-centered. They also address clinical accountability when they state the clinician must not only understand the literature, but understand how and when to apply it. Below is a good excerpt from this piece (thanks for sharing Michael):

        “Clinical expertise includes the general basic skills of clinical practice as well as the experience of the individual practitioner. Clinical expertise must encompass and balance the patient’s clinical state and circumstances, relevant research evidence, and the patient’s preferences and actions if a successful and satisfying result is to occur. Accomplishing this goal often involves sorting through tradeoffs. The traditional turf of clinical expertise characterised by sizing up the patient’s clinical state has never been more important; getting the diagnosis and prognosis right and knowing how to administer a treatment (whether just a pill or a complex technical procedure) often demand more skill now than ever before because the options are many and more is riding on doing things right. Clinicians must be atop not only the research evidence, but they must also acquire and hone the skills needed to both interpret the evidence and apply it appropriately to the circumstances — doing the right things. Finally, although communication with patients has always been important, determining the role in decision making that patients desire, ascertaining their preferences, and providing patients with the information they need to make an informed choice has never been more challenging.”

  1. I think you’re correct about the value clinical expertise is given in patient care. Sometimes “clinical expertise” can be just something a “guru” or some sort of a mentor has said or what he thinks or has observed. Then this is being passed on and as it is something you have been told it has to be right, right? Well, not really – what if the person telling/teaching it to you got it wrong?

    I have spent a good amount of moments thinking about this and cognitive dissonance when it comes to say, manual therapy, acupuncture etc… it might have it’s time and place when used correctly on a correct patient in the right time. But this does not make these treatment panacea or even prove that they work as believed in the first place.

    I enjoy your blog with nice thoughts and good, positive modern and well thought opinions! Keep it up!

  2. Hey Joe,
    I really appreciate this piece and it sits deep in what I believe in too. A small survey that I performed on my site last year showed majority of clinicians utilize their experience:

    http://intouchpt.wordpress.com/2013/10/25/evidence-based-practice-survey-results/

    I do not think having clinical expertise is BAD at all, as I like what you’re proposing in regards to the definition. There is a difference in: 1 yr of experience x 10, or 10 yrs of experience.

    I feel that since we are a scientific community and field, we need to adapt to the scientific advances. However slow in our field, this should be a requirement that each independent person should strive.

    I find it hard to make ‘old dogs do new tricks’ in regards to the therapists with say 10-15+ yrs of experience. What do you recommend saying to these guys/gals?

    Harrison

    • Our anterior cingulate cortex, when posed with two competing hypotheses, will often chose the one that is most familiar. That is why it is so difficult to restructure beliefs. So I am not quite sure what to say to “experienced” professionals other than keep up with the literature, accept a bit of clinical uncertainty and don’t ever become “comfortable”.

      We all chose to become professionals. We did not chose to be technicians. In becoming a healthcare professional, you must accept a certain amount of accountability and responsibility to uphold professional practice. I think John Ware, bluntly said this within the comments on another site (read the 2nd half of comments): http://www.evidenceinmotion.com/about/blog/2014/03/what-differentiates-physical-therapy/#comments

  3. Great post Joe! I could definitely get behind your new proposed model. I tend to think that clinic experience really doesn’t mean much unless the clinician was focused on evidence based practice and improving clinical reasoning throughout his/her “experience.” If not, then what good is the “experience.” Although originally a third of the original model, it appears to me to have overtaken at least half, clinical experience is usually a clinicians fall back to the question “what is your reasoning for employing that intervention?” This often makes me cringe.

    Moving past “experience” into new treatment paradigms and philosophies backed by research can be touch, cognitive dissonance is a pain in the butt, but it’s necessary to move forward as a profession.

  4. I think changing the order and moving “patient values and preferences” to number 2 of 3 begins to address the dilemma that I face on daily basis balancing Evidence Based Practice versus Patient Centered Practice. Often what the patient prefers is not supported by evidence. In the real world patients are not as excited about getting Evidence Based Practice as they are in receiving Patient Centered Care. I have often thought Sacketts’s model placing patient values third in the sentence has contributed to the development of Patient Centered Care Model.
    Damien

    • Sorry if this was confusing in the post, but Sackett did not put preference over which variable was more important or which should be ranked higher. When I numbered, 1. 2. 3., I did not intentionally place one higher than another.

  5. Joe,

    I think you have raised an important issue of how “clinical experience” is defined and utilized within the evidence base triad. Obviously, our own experiences and observations are extremely prone to error and bias, that left unchallenged or critically appraised they are likely to lead confirmation bias and post hoc ergo propter hoc (http://en.wikipedia.org/wiki/Post_hoc_ergo_propter_hoc). Unfortunately, our clinical data can only take us so far, can only answer certain questions, and has certain limitations (even when assessed and analyzed critically). But, it’s necessary and vital, but only a component of the “evidence” based triad.

    We need to explicitly teach what it means to appropriately develop and assess experience. As mentioned metacognition and proper thinking skills are vital. Yet, these actual concepts and skills are rarely taught in the same detail nor practiced at the same frequency as our procedural interventions.

    In addition to the critically re-defining appropriate clinical experience, we need to also critically assess what we mean by “best available evidence.” As has been discussed much recently, most are referring to the best clinical outcomes evidence a la RCT’s when referring to evidence. Such a narrowly defined scope of “best available evidence” is sucking the critical thinking out of clinical practice with a resulting volleying of RCT’s for the justification of interventions as opposed to deep, critical thinking processes.

    I have discussed some of the issues of evidence based practice and the necessity of critical thinking in these two posts

    http://ptthinktank.com/2014/01/06/metacognition-critical-thinking-and-science-based-practice-dptstudent/

    http://ptthinktank.com/2013/11/05/agree-to-disagree-the-less-wrong-way/

    In regards to patient preference, I think this also needs a critical appraisal. Allowing patient preference (or request) guide decision making within medicine is part of the reason for over utilization of imaging, over prescription of antibiotics for cold symptoms, and other “unnecessary” or unsupported medical interventions. How do we respect patient’s preferences and understanding without increasing costs and utilization of low effectiveness, “needless” procedures? I think the patient preference leg requires an explicit analysis of the patient’s narrative, concerns, desires, goals, and expectations. Gently interacting and guiding the patient while meeting them where they are follows.

    I applaud your efforts to assess and conceptualize this difficult, but important topic.

    • Excellent discussion and some really important points made above about the lack of a good account of how clinical expertise is integrated into evidence-based practice. An equally important issue is the nature of clinical evidence. It is often overlooked that the ‘e’ in ebp has many flaws; there are some serious questions to be answered about how evidence is gathered. Empiricism has many critics and in my opinion has not answered the charges made against it adequately particularly where manual therapy is concerned.(Kerry et al. 2013; Nevo & Slonim-Nevo 2011). This is no way detracts from the reasonable criticism of clinical expertise or expert opinion as a poor driver for health-care but balances the argument. It is not that clinical expertise is better; it is that we should not accept the ‘evidence’ blithely even if it adheres strictly to accepted appraisal techniques.
      Of incidental note is the irony when you consider that trials, systematic reviews and meta-analysis (Menke 2014) are reaching such complexity that we are needing ‘expert opinion’ to understand them. Full circle.

      Kerry, R. et al., 2013. Analysis of scientific truth status in controlled rehabilitation trials. Journal of evaluation in clinical practice, 19(4), pp.617–25. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22568746 [Accessed February 5, 2014].
      Menke, J.M., 2014. Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis. Spine, 39(7), pp.E463–72. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24480940 [Accessed March 21, 2014].
      Nevo, I. & Slonim-Nevo, V., 2011. The Myth of Evidence-Based Practice: Towards Evidence-Informed Practice. British Journal of Social Work, 41(6), pp.1176–1197. Available at: http://bjsw.oxfordjournals.org/content/early/2011/01/24/bjsw.bcq149 [Accessed February 26, 2014].

  6. Fantastic comments – I agree with all you “young folks”! I have been practicing for over 3 decades in this field, and always find new treatment techniques, devices, ideas and concepts, etc. and I definitely can be taught and learn “new tricks”! It’s all about attitude and finding ways to keep it fresh!

  7. […] Adam Rufa and Joe Brence of Forward Thinking PT examine the concept of “clinical experience.” Their post series, The Experience Wall, assesses perceptions, memories, and interpretation within clinical care. Joe Brence highlights how experience may not result in linear increases in clinical skill and outlines a new definition of clinical experience: […]

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