Are we providing doctors with the training and tools for lifelong learning?
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7220.1280 (Published 13 November 1999) Cite this as: BMJ 1999;319:1280
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Thank you to Drs. Mackenzie and Webb for your concerns about our
manuscript. Please go the webpage mentioned with reference # 20 and follow
the links to downloading InfoRetriever. You will find information their
under clinical guidelines than contain all the AHCPR guidelines, as well
as many other evidence-linked guidelines. Under the heading "acute low
back pain" you will find reference to "physical therapy" which is given an
"X", for being harmful.Once you have downloaded this software and
installed in on your computer, access time to this information is less
than 45 seconds. It is available in both a desktop and handheld version.
Competing interests: No competing interests
EDITOR - A recent article (1) reviews the complex conditions in which
doctors have to deal with the great amount of new knowledge and the life
long learning process.
EBM is a strategy to face this problem, encouraging doctors to learn how to
find evidence that helps them to make good clinical decisions in health
care (2).
When trying to introduce EBM in clinical settings, it is possible to see
that the process is well accepted in its principles but rarely put
into practice. One of the crucial points is the clinical questions doctors
try to answer through the EBM process.
As they are embedded with traditional concepts that "day-to-day"
experience and sound theoretical concepts are enough to make good clinical
decisions, often they do not attempt to find answers to common clinical
questions.
They do not take into account the short life-time of medical knowledge and
feel comfortable with their old acquired ones. However, they accept to
revert to literature searching for answers in cases where their knowledge
is scarce, and this is particularly evident when they face rare cases.
We see during EBM teaching sessions that when learners are invited to
write down clinical questions related to any recent case they treated,
quite often only rare cases are presented.
It is in those cases where EBM helps the least because usually evidence is
conformed by opinions, short case series or mere weak observational
studies, frustrating their hope to find an answer based on high level
evidence.
Then, they question why practise EBM if it only gives sound answers in
situations where they know what to do and it fails when they don't?.
Teachers have to lay the emphasis on the fact that the best management for
common situations must be reviewed periodically to offer patients
decisions based on updated knowledge. It is in this field that EBM
strategy is
particularly useful in helping to answer clinical questions that matter, that is, those that affect the majority of patients. Evidence-based guidelines could
play an interesting role in this process. Although the management of rare
cases has to be reviewed through the same process and expectation of
sound
answers has to be moderate, that is not enough to rule out EBM strategy.
References:
1. Shaughnessy AF, Slawson DC. Are we providing doctors with the training
and tools for lifelong learning?. BMJ 1999; 319: 1280
2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS.
Evidence based medicine: what it is and what it isn't [editorial]. BMJ
1996; 312: 71-2
Roberto Lede, MD, PhD.
Pablo Copertari, MD.
Argentinian Institute for Evidence Based Medicine,
Av. Roque Saénz Peña 825, 6º piso,
1035 Buenos Aires,
Argentina
Competing interests: No competing interests
As a busy person with lots of things to do I found this week's BMJ
Quite fun. Short items easy to cover quickly.
I found this article on POEMS and,lo and behold,a mention of some
"evidence" not seen before about the AHCPR guidelines. This must be an
example of what they are talking about I thaught. All I need to do is
fight my way through the computer and internet and there it will be - is
it hell! At least as far as the search engines allow me to look it may be
there for all I know! Not to mind it will be there as a http link from the
super BMJ page as advertised.
When I get there what do I find but the old style stuff only moe
difficult to read as its on a screen not paper. Not only this NO MENTION
of the AHCPR guidelines anywhere!
If you promise something do try to deliver.
Be Bold Next time
Tim Webb
Competing interests: No competing interests
I agree that the amount of information being made available is large.
In order to ease the consumption of new evidence POEMs sound like a
good idea. However, it is vital that the information contained in POEMs be
accurate. In the paper copy of this edition I read with interest a POEM
about
acute back pain and physiotherapy said to come from AHCPR guidelines.
I then accessed the AHCPR and was surprised not to find the word
physiotherapy
anywhere in the article.
I currently work in a DGH and keep my practise as evidence based as
possible.
Current treatment of patients with back pain includes provision of as much
information as possible to the patients. Management of pain and
minimisation
of disability are important. Patient choice requires that they have as
much information as possible to make an accurate choice.
POEMs would be useful as long as they were accurate. The burden of
ensuring accurate formation of POEMs would be great for whoever was
enlisted to the task.
Competing interests: No competing interests
POEMS and physiotherapy for back pain
The concept of POEMS or "Patient Oriented Evidence that Matters" (BMJ
vol 319, 13th November 1999,p12801) could potentially be very helpful for
clinicians and their patients. However, as with any brief summarised
information accuracy is essential. Otherwise it can be seriously
misleading.
POEMS statement said Evidence based Treatment guidelines such
as AHCPR on acute back pain show that physiotherapy is actually harmful
for a patient with low back pain. The US clinical practice guidelines
produced in 1994 by the AHCPR (Agency for Health Care Policy and Research
19942) synthesised all the evidence that was available then.
On checking
out these guidelines we found no such statement. They do state that there
is no evidence for the effectiveness of physical agents and modalities
such as ice, heat or electrotherapy although some patients find these
provide symtomatic relief. They also state that any risks are believed
to be small.
More importantly the US guidelines along with the more recent UK
Guidelines from the Royal College of General Practitioners3. and the
accumulating research evidence shows that exercise and encouraging
movement and graded physical activity is the recommended method of
managing back pain. Manipulation also may be effective in both the acute
and chronic stages of back pain although the current results are
inconclusive4 Further research is being carried out in these fields. The
physiotherapist is the health care professional who is best placed to
activate the patient with acute back pain and help them to overcome any
fears of reinjury and get back to normal activities. It seems therefore
that POEMS have made a statement that is most regrettable and potentially
harmful itself.
Jennifer Klaber Moffett
Deputy Director
Institute of Rehabilitation, University of Hull, 215 Anlaby Road, Hull,
HU3 2PG
Laura Constable
Superintendent Physiotherapist
Marmaduke Health Centre, Marmaduke Street, Hull
David Crick
General Practitioner
723, Beverley High Road, Hull, HU6 7ER
References
1 Shaughnessy A, Slawson D. Are we providing doctors with the
training and tools for lifelong learning? British Medical Journal
1999;319:1280.
2 Agency for Health Care Policy and Research. Acute low back pain
problems in adults. Clinical practice guidelines. Rockville: AHCPR, 1994.
3 Royal College of General Practitioners. Clinical guidelines for the
management of acute low back pain. London: RCGP, 1996.
4 Koes B, Assendelft W, Heijden G, Bouter L. Spinal manipulation for
low back pain: an updated systematic review of randomised clinical trials.
Spine 1996;21:2860-2873.
Competing interests: No competing interests