The use of the term “evidence-based practice” has gained significant traction in the athletic training and sports health care world. I couldn’t help but notice the prevalence of the term at this year’s National Athletic Trainers’ Association (NATA) Annual Meeting and Clinical Symposia in San Antonio, Texas. It seemed to me that every other presentation somehow had the term evidence-based worked in the title. As a proponent of advancing evidence-based practice in the athletic training profession, this should have been a welcome sight. However, my cynical nature forces me to look a little deeper.
Much of what I see today that claims to be evidence-based are papers or presentations that are merely referencing current or historical research. In other words, we are starting to call anything we spend some time to reference evidence-based because that has become a buzz-word. Citing important research to support our assertions and recommendations is a basic element that should serve as a minimal requirement for any clinical, educational, theoretical, or scientific publication or presentation in a health care profession. However, a presentation or paper that is evidence-based should be fundamentally more complex than this because it is necessarily based on the principles of evidence-based practice. Furthermore, evidence-based practice is about patient care and should be limited to the categories of clinical practice (ie, therapy, prevention, etiology, harm, prognosis, diagnosis, differential diagnosis, symptom prevalence, economic and decision analysis). We should avoid applying the term “evidence-based” to concepts outside of patient care such as education and administration. The use of evidence-based language for nonpatient care topics merely highlights our misguided emphasis on citing evidence while failing to fully appreciate the complexity of evidence-based practice. My current conclusion is that we still don’t really understand the basic principles of evidence-based practice, yet.
The principles of evidence-based practice are based on the integration of the best research evidence, clinical expertise and each patient’s unique values and circumstances into patient care.1,2 Each of these three key elements requires further examination because evidence-based practice is more than a concept; it is a culture. For an evidence-based culture to thrive, all of the cultural members, including clinicians, scientists, and educators, must understand and embrace the principles on which the culture is based. My current (grossly generalizing) sense of our evidence-based culture goes something like this:
- Clinicians don’t really understand the whole evidence-based push and interpret it as something that the scientists and educators, who don’t understand the realities of their day-to-day patient care issues, are trying to tell them to do.
- The scientists view it as a validation of their existence because they are the ones who are supposed to be producing evidence in the traditional sense, but they are highly skeptical, if not outright offended, about the relegation of the mechanistic and laboratory-based research they are producing to lower levels of evidence.
- Some educators don’t understand evidence-based practice and are worried about it becoming one more thing they must try and figure out how to teach, while some educators really do understand it and recognize the difficult task of trying to merge the best research, clinical expertise, and patient values into a unified framework to teach future health care professionals.
Suffice it to say, despite some outward signs that we are moving towards evidence-based practice (eg, presentation titles), an evidence-based culture is most certainly not pervasive and thriving in athletic training.
I would like to address each of the three key principles of an evidence-based practice culture. The first principle to address is the use of the best research evidence. As I reflect on our current culture, I can’t help thinking that perhaps the mere structuring of the term evidence-based practice has contributed to the misconceptions we have developed. In a culture that should be first and foremost about patient care, we have over emphasized “evidence” and have interpreted “best research evidence” to mean simply referencing a published study or textbook. Because key elements of clinical expertise and patient values don’t overtly appear in the term evidence-based practice, they have almost been entirely forgotten or ignored, despite the fact that they are fundamental aspects of nurturing an evidence-based culture. Our omission of clinical expertise and patient values has reduced the complex nature of evidence-based practice to the mere citing of research (ie, evidence). Even worse, we have failed to recognize the responsibility to rigorously determine the “best research evidence” and have instead defaulted to the simple task of identifying whatever evidence is readily available.
Evidence-based practice requires that the available research be critically appraised for quality and graded with a hierarchical level of evidence, such as that provided by the Centre for Evidence Based Medicine ( http://www.cebm.net/index.aspx?o=1025). Furthermore, any clinical recommendations for patient care derived from this evidence should be graded to determine the strength of the recommendations using a taxonomy, such as the one developed by Ebell et al.3 Therefore, an evidence-based approach to patient care requires a structured approach to determining the best available evidence through critical appraisal and assessing the strength of the clinical recommendations made based on the quality of the evidence. This level of rigor in assessing the available evidence is almost completely lacking in many of the products labeled as evidence-based. Currently, Athletic Training & Sports Health Care, the Journal of Athletic Training, and the Journal of Sport Rehabilitation all possess some publication type specifically targeted to address evidence-based practice, which is excellent. However, these journals currently fail to identify the levels of evidence of the original research studies that they publish, thereby limiting the ability to quickly and accurately identify the quality of published research studies for clinical decision-making. Accurately identifying the levels of evidence of the published research in these journals is a basic and necessary step towards establishing an evidence-based culture.
We should turn the concept of evidence-based practice on its head and start focusing on practice-based evidence. Currently, the majority of evidence that athletic training scientists are producing provides the lowest levels of evidence from which to inform clinical-decision making because it is not performed on patients with a specific injury or illness of interest, fails to assess a specific intervention of interest to a comparator intervention, or fails to measure patient outcomes. Consequently, we are producing a great deal of research, but it is of limited value to clinicians seeking answers to focused clinical questions. Clinical questions should be developed using the PICO format (patient or problem, intervention, comparison intervention, outcome). It is difficult to teach students about evidence-based practice and the importance of asking focused clinical questions when the evidence-base we are directing them to regularly fails to provide meaningful answers to their questions. If you never enjoyed the thrill of catching a fish, you may one day stop throwing your line in the water. The same is true for enthusiastic students with inquisitive minds seeking answers to their questions about patient care. How many times can we expect them to conclude that the only evidence available is from a different patient population that seems inapplicable, is lower level laboratory-based evidence that only speaks to the theory, or that the available evidence is all underpowered and inconclusive, before we assume they will stop fishing?
The second principle of evidence-based practice requires that patient care decisions take clinical expertise into account. A randomized controlled trial isn’t available to answer every clinical question. In fact, as I have just discussed, we have very little high quality evidence to guide our clinical decisions. Therefore, we have to rely heavily on clinical expertise to direct patient care. Ideally, clinicians would be regularly assessing and documenting the outcomes of the care that they are providing and then engaging in some form of best practices review to improve the care they provide. Unfortunately, I have observed very little of these types of practices in athletic training, which hampers our ability to make well-informed clinical decisions. Clinical expertise does not mean clinician opinion. Clinical expertise is predicated on thoughtful clinicians who assess the effectiveness of the care they provide on a regular basis through the assessment of patient outcomes; keeping abreast of the current evidence in the literature; engaging in peer-review and quality improvement activities (eg, clinical case studies or grand rounds); and continually striving to provide the best care possible. Unfortunately, literature describing best clinical practices and the establishment of clinical practice guidelines based on the principles of evidence-based practice is currently lacking in athletic training. This severely undermines our ability to establish an evidence-based practice culture.
As the actual providers of athletic training services to patients, clinicians are on the front lines of evidence-based practice. Therefore, it is imperative that clinicians determine the patient care problems they are facing and the types of clinical questions for which they are seeking evidence and work with scientists to create new evidence. Clinicians should be the initiators of clinical research questions aimed at improving patient care and scientists should be partnering with clinicians to answer these important clinical questions. Educators have a responsibility to teach future health care providers how to become clinician-scientists who can generate focused clinical questions and collect clinical research data in collaboration with scientists to improve patient care outcomes. Clinicians have the responsibility to model behavior as an evidence-based practitioner.
Currently, even if scientists were producing the right kind of evidence and educators were teaching students how to access it, the lack of availability of this evidence at the point-of-care limits clinicians’ ability to practice in an evidence-based manner. Clinicians who are practicing outside of institutions of higher education or academic hospitals (eg, clinic, secondary school, industry, physician office) frequently lack access to point of care products, such as Rehabilitation Reference Center, for retrieving evidence. Many clinicians have no access to a full text searchable database such as CINAHL, SPORTDiscus, or Rehabilitation and Sports Medicine Source. Even in the college and university setting, there may be a lack of access to high quality medical evidence at smaller liberal arts institutions. Therefore, even if high quality patient-oriented evidence were being produced, and if students were being taught how to use the evidence, and this use was being modeled for students by veteran clinicians in their educational environment, there lies a strong possibility that, after leaving the nest of academia, many new clinicians would be completely cut off from access to the best available evidence. This represents a major obstacle to the future of evidence-based practice in athletic training that requires significant attention.
The final, and most frequently neglected, principle of evidence-based practice is the integration of each patients’ unique values and circumstances into patient care. In this regard, all parties (clinicians, scientists, educators) are guilty of failing to recognize that, as health care providers, our primary responsibility is to the patients that we serve. Many among us still advocate against the use of the term “patient” arguing that we treat “athletes.” In fact, a review of our collective literature would suggest that our clinicians are caring for only athletes, our scientists are focused primarily on subjects, our educators are focused on students, and our professional association is concerned only with its members. So, who is looking out for our patients? We are a very caring profession and concern for the patients that we serve may be implicit in all that we do. But, it is time for a focus on patient care to become explicit.
Focusing on the patient requires that we consider the patient’s unique values and circumstances and integrate these into the care that we provide. This requires assessment of patient-centered variables such as quality of life and patient satisfaction.4 For a culture of evidence-based practice to thrive in athletic training we must assess the impact of our care through the eyes of our patients. It is not enough to measure care using only clinician-based measures such as strength, range of motion, radiographs, blood work, etc. Additionally, it is completely inadequate to continue to study only small samples of healthy subjects in controlled-laboratory settings and expect that our results can be useful for improving patient care. Instead, clinicians and scientists must partner to incorporate reliable and valid patient self-report measures into clinical practice that provide us with the patients’ perspectives about how our interventions are affecting their perceived health status and their satisfaction with the care that we are providing. To become an evidence-based profession, a major shift in the manner in which we assess the care that we provide needs to occur and must focus on the perspective of the patient. Achieving this paradigm shift will require the collective cultural buy-in of the clinicians, scientists, and educators.
New professionals in any health care profession lack clinical expertise. Recently, many athletic trainers have lamented about how our new professionals are not prepared to practice independently. This is a common concern among nearly all health professions. Adoption of an evidence-based practice culture could help to lessen these concerns because evidence-based clinicians, scientists, and educators would:
- Recognize that new professionals lack clinical expertise and validate their need to seek counsel from veteran clinicians, while holding those veterans accountable to be role models and mentors as clinical experts.
- Require all clinicians to assess the outcomes of their care, thereby providing immediate feedback about the effectiveness of their interventions and bench-marking of new clinicians quality of care.
- Hold scientists accountable to produce high quality patient-oriented evidence that new clinicians could access to help them in their clinical decision making.
- Hold educators accountable to teach evidence-based strategies for clinical decision making and hold clinicians accountable to model this behavior in clinical practice.
This brings me to my final point and the basic thesis of this editorial, which is now long overdue: Whether we view ourselves individually as a clinician, educator, or scientist, we are first and foremost health care providers. As such, we must dedicate ourselves to improving the lives of our patients through better patient care. In order to cultivate a culture of evidence-based practice, we must each view ourselves as a clinician, scientist, and educator who is seeking to optimize our patient’s outcomes. Take off whichever hat you wear on a daily basis for a moment and imagine the positive impact on our patients if: clinicians incorporated patient-oriented outcome measures into their daily practice; scientists and clinicians used this evidence to collaborate and answer important patient care questions and educators began teaching evidence-based practice principles to students, thus enabling them to ask clinical questions and seek the best available evidence from which to guide their clinical decision making. Instead of the misunderstanding, bickering, and lack of respect that clinicians, scientists, and educators tend to show one another, we would begin to work together synergistically to provide the best possible patient care to those who are looking to us for help. Imagine that.
This is an exciting time for athletic training as things are continually changing—a sign of growth, maturity, and responsibility as a health care profession. Embracing and fostering a culture of evidence-based practice represents the next great change and will require the collaboration and work of everyone: clinicians, scientists, and educators. There is some good work being done to achieve this. The NATA Research & Education Foundation has held an evidence-based practice symposium and is allocating funding towards clinical outcomes research. Recently, a Foundation funded project grant has developed a website ( www.coreat.org) with the goal of educating and training athletic trainers to use technology for the collection of health care outcomes data in order to practice in an evidence-based manner. The NATA Pronouncements Committee has mandated that the strength of recommendations in all Position Statements be graded based on the levels of evidence from which they are made. The NATA Executive Committee for Education recently identified the infusion of evidence-based practice into education as one of its top three priorities and concepts of evidence-based practice, clinical outcomes, and clinical decision making are being incorporated into the fifth edition of the Educational Competencies. We are still in the very early stages of the evidence-based practice movement in our profession. But, given the efforts outlined above, I am optimistic that we are headed in the right direction. It is incumbent on us as health care providers to come together as clinicians, scientists, and as educators, to establish a new culture of collaboration around evidence-based practice. Our patients deserve it.
- Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn’t. BMJ. 1996;312:71–72.
- Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-based medicine: How to practice and teach EBM. 3rd ed. Edinburgh: Elsevier; 2005
- Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004;17:59–67. doi:10.3122/jabfm.17.1.59 [CrossRef]
- Wade DT. Outcome measures for clinical rehabilitation trials: Impairment, function, quality of life, or value?Am J Phys Med Rehabil. 2003;82:S26–31.