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Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things—to help, or at least to do no harm. The art consists in three things—the disease, the patient, and the practitioner. The practitioner is the servant of the art, and the patient must combat the disease along with the practitioner.
—Adapted from Hippocrates, Epidemics, Bk. I, Sect. II
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We began this book with these words from Hippocrates, and they seem fitting for the book's conclusion as well. Over 2000 years ago, he identified that health care practitioners reach excellence by understanding the art of care, by recognizing the patient as a partner in care, by making accurate diagnoses and prognoses, and by knowing what helps (and harms) our patients—all the elements of evidence-based practice (EBP).
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If these principles have been with us for 2000 years, one might ask why they have not been adopted fully into health care. We've discussed the barriers to individuals adopting change in Section IV, but it is also worthwhile to identify the reasons that reflective practitioners have opposed the adoption of EBP because of serious concerns about its appropriateness and the barriers that arise from the very structure of the health care system.
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We will explore here the ways that EBP has been implemented by physical therapists across the country and will conclude with some thought about the possibilities for the future.
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CONCERNS ABOUT ADOPTING EBP
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Reasonable and reflective people have expressed some reservations about the very premises of EBP. Because these are such important issues, we will explore them here.
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EBP Interferes With the Clinician's Decision Making
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This concern about EBP is generally offered in one of two ways. Some complain that EBP is simply a tool of insurance companies to be used in preventing practitioners from providing the right care in order to decrease the amount spent on care.1 While it is possible that an insurance company can misuse a particular piece of evidence to make incorrect decisions, these actions can be challenged and corrected. This possibility is far outweighed by the improvement in both quality and cost of care that can be achieved when practitioners use those tests and interventions that are shown to be more effective than others. This potential has led policy groups to recommend that the use of evidence be incorporated into health care practice. One such group is the Institute of Medicine (IOM), an independent group composed of scientists and practitioners and part of the National Academy of Sciences. They have examined the issues around EBP and have recommended that it is imperative that resources are made available to conduct systematic reviews and to develop trustworthy clinical guidelines. They state that such efforts will succeed ...