Can Evidence-Based Medicine Be A Reality In Practice?

It is said that the best science is repeatable science. If you pour x into y in certain measures and under specific conditions, z will occur every time. In podiatry, such certainty is not always that certain. The treatment regimen one utilizes for the lower extremity wound of one patient with diabetes may work in healing the diabetic ulcerations of three other patients but not a fourth. Her wound might require a different therapy or a combination of therapies. Her z requires a different x and y. However, the regimen you prescribed for your first patient should work. It has been written up in a journal and there are statistics that vouch for its success. However, your “gut,” that wisdom earned through years of practice, tells you to try something else. Such is one of the controversial scenarios at the heart of whether podiatric practices should be doing more to incorporate the guidelines and methodologies of EBM to diagnose and treat their patients. Add to this the relatively small (albeit growing) body of published, peer-reviewed podiatric scholarship available to practitioners and one can easily surmise both ends of the spectrum when it comes to EBM in podiatry. There are those who feel the only treatments worth pursuing are those with documented proof behind them. Then there are those who, for reasons of access or simple reliance on experience, feel that EBM documentation is fine but ultimately unnecessary. While there are intriguing views on either side of the EBM debate, the emerging consensus is that the safest ground is likely somewhere in the middle. Defining EBM’s Role In Podiatry William Fishco, DPM, says the role of EBM in podiatry is no different than any other aspect of a medical specialty. “As our profession is evolving, we are moving away from anecdotal evidence, which is much of the dogma that is taught in podiatric medical schools, and turning toward EBM, which gives scientific proof to evaluate outcomes of various interventions,” explains Dr. Fishco, who is in private practice in Phoenix and is on the staff at the Phoenix-based John C. Lincoln Hospital-Deer Valley. “Evidence-based medicine is not new to healthcare,” notes Paul Kim, DPM, an Assistant Professor at the Arizona Podiatric Medicine Program at Midwestern University. “Its integration for the delivery of healthcare is being felt throughout all medical specialties. Evidence-based medicine encourages the practitioner to stay abreast of current treatment options and find superior ways of delivering care. These alterations in the way that we practice will culminate in improved patient outcomes.” Kathy Satterfield, DPM, says EBM does not have to be this “frightening, ivory tower idea that scares off the average Joe.” She believes more DPMs are incorporating EBM into their practices without even realizing it. “I think that they would probably just say that they use good practices,” explains Dr. Satterfield, a Clinical Associate Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center at San Antonio. “They look for gold standard studies performed by reputable researchers in major academic health centers without undue industry influence. By doing so, they use the best research to inform their decisions about clinical practices that affect their patients’ lives.” David Armstrong, DPM, PhD, waxes philosophical when contemplating the role of EBM in podiatric practice. “It is about getting at the truth,” posits Dr. Armstrong, a Professor of Surgery and Associate Dean of the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago. “For some people, the truth is what they see in their office when they are handling a patient or in the operating room. They might say, ‘I did this and this happened, and that is the truth.’ That is very valid. “Another person might say, ‘Well, I just reviewed this meta-analysis of 50,000 patients and I believe this is true.’ That might be contradictory to the truth one sees in the office or the clinic. The real truth lies somewhere in between.” Getting to that level of “truth” might prove onerous for DPMs who lack or think they lack access to certain technological resources. Others may feel they have trouble finding the right materials even they do have that access. Tanya Thoms, DPM, says the latter poses particular problems for interested physicians. “The EBM Web sites that are sharing systematic reviews are, for the most part, focused on internal medicine right now,” points out Dr. Thoms, an Assistant Professor at the Arizona Podiatric Medicine Program at Midwestern University. “That means a lot of the podiatric-related issues might not be covered. A site might have resources on, for example, diabetes but the research is on insulin versus oral medication as opposed to podiatric topics. That research simply might not be available right now. We need to fill in the gaps.” As Dr. Kim notes, there still is a paucity of medical data to support many of the clinical decisions that DPMs make. However, he says as clinical researchers continue adding to the body of medical knowledge, information about specific topics will be easier to obtain. Can EBM Point To Better Treatment Choices? What proves the essential worth of any treatment approach, evidence-based or otherwise, is whether that approach provides DPMs with better treatment choices. Advocates for EBM tout evidence as the best judge of good treatment. “The EBM approach provides a framework to compare and contrast treatment options,” explains Dr. Kim, the current Chairman of the Evidence-Based Medicine Committee of the American College of Foot and Ankle Surgeons (ACFAS). “It is important to note that EBM still relies on the physician’s clinical expertise and the patient’s values and circumstances. Ultimately, EBM allows the physician and patient to make better informed decisions.” Of course, the advent of the Internet has made patients better informed about their treatment options. Dr. Thoms feels this plays directly into the strengths of an EBM approach. “(The patients are) already on the Web,” points out Dr. Thoms. “They are taking an active role in their healthcare. They are looking for their own answers and finding articles on their condition. However, they may not always get the right articles, the ones that are of value. Evidence-based medicine gives us a way to have that conversation, to show them an article that truly is valuable in treating their specific condition.” Could EBM Spur Greater Acceptance Of The Profession? Some have made the argument that EBM would help the whole of podiatry rectify the mistaken perception that it is something of an underclass in medicine. In this frame of thought, compiling a library of scholarship on podiatric pathology would provide a semblance of proof or legitimacy the specialty lacks in certain quarters. “Podiatrists have been fighting to be equal to allopathic physicians and mainstream medicine for years,” explains Dr. Fishco, a faculty member of the Podiatry Institute. “Evidence-based medicine is now a critical teaching tool and is part of current patient care. All of medicine is utilizing EBM so why should we be any different?” “Podiatric medicine is not alone in its attempt to infuse EBM principles into practice,” concurs Dr. Kim. “The era of anecdotal-driven medicine is slowly being replaced by EBM. This is an opportunity for the podiatric profession to lead the way in this integration, which would certainly enhance our visibility to other healthcare providers.” Dr. Armstrong feels peer-reviewed publishing is one of the keys to wider acceptance. “I believe the secret to our growth and our survival is in opening ourselves to critique,” notes Dr. Armstrong, a past member of the National Board of Directors of the American Diabetes Association. “When you open up the profession to scrutiny, warts and all, what you are doing is exposing the depth, quality and richness of the profession. Scholarship, in reporting what we do, exposes the rest of medicine to the full spectrum of our profession and, over time, this can only yield positive results.” Combination Therapies: Where Is The Evidence? One critique of EBM in a podiatric context is the lack of published material on combination therapies, a point that is not lost on Dr. Armstrong.“All of us mix and match,” he says. “There is still an element of alchemy in what we do. Obviously, some cases required a combination of various therapies. We need to assess therapies individually and then together in a systematic process.” Dr. Kim notes that, in many instances, the literature either does not address or does not sufficiently address a specific clinical question, a limitation he describes as “somewhat frustrating” for those attempting to apply EBM principles. However, he notes there is good news in that new research is constantly being published on a daily basis. Further, Dr. Kim says clinical researchers are constructing their research to answer questions that are raised through the EBM process. Dr. Thoms argues that EBM is still a young approach and is going through something of an evolutionary process. She says although there are some randomized controlled trials that have multi-drug comparisons, there are not at this point many systematic reviews of combination therapies. “That does not mean those reviews are not up and coming,” she says. Making The Case For Untested Treatments Another criticism of EBM comes from DPMs who feel the approach might shackle them into only providing patients with treatments that are backed by testing and peer-reviewed publication. This perceived lack of flexibility may keep some podiatrists, particularly those in smaller practices, from incorporating an evidence-based approach to their work. “There is certainly a place for novel treatments that have not yet been thoroughly tested,” admits Dr. Kim. “What is important is how these treatments are integrated. I do things all the time that are not necessarily supported by the literature. This is only partly my fault. In many cases, there is minimal or a lack of guidance from the literature on the appropriate treatment course.” “This is not one-stop shopping,” explains Dr. Thoms. “Evidence-based medicine does not dictate, ‘This is the article. This is the research and you must do what this says.’” She points out that one article on a given modality may not apply in a particular patient’s case because he or she may have something else going on. However, Dr. Thoms says EBM does help podiatric physicians “expand our options” with the patients. “One has to remember that medicine and surgery are still an art despite the obvious importance of EBM,” notes Dr. Fishco. “Certainly, one does not want to perform a treatment that may have a deleterious effect on a patient. However, if sound medical and surgical principles are utilized, then non-EBM treatments are acceptable. If nobody ever took any chances, then things like the artificial heart would never have been developed.” “Ultimately, everything we do should be rigorously examined and compared,” maintains Dr. Kim. “This critical appraisal results in more consistent and better outcomes for our patients.” Emphasizing EBM In The Schools And Residency Programs According to Dr. Kim, acceptance of EBM begins at the podiatric medical schools with EBM being integrated into the curriculum and becoming a familiar part of students’ vernacular. Dr. Thoms concurs and notes that teaching a practical approach to EBM is most useful. “We teach students what databases are good for general medicine versus podiatric medicine,” she explains. “We teach them how to come up with a clinical question and how they can actually take some of those words and put them into a search engine, and come up with something valuable. Really, when you are on the fly in the clinic, you do not have a lot of time so you cannot spend 45 minutes digging through databases to find articles you need.” Through practical and direct application of EBM principles, students and residents are becoming immersed in the methods of EBM in the earliest of experiences in the field. “My students and residents already have the expectation that EBM will be discussed and applied to my patients,” says Dr. Kim. “For example, if a patient presents to my office for surgical correction for hallux limitus, the various surgical treatment options will be discussed with the patient. My students will then find the best evidence in support of the various treatment options. This best evidence will be evaluated and a treatment plan would be instituted. This sometimes takes a few days or quickly at a computer terminal. “Once this generation enters practice, EBM will be a natural extension of what they do.” Understanding The Challenges Of Incorporating EBM Into Practice The question remains: Is it possible for evidence-based medicine to be adopted in podiatric practices? If the answer is yes, then there is the question of feasibility. Do the resources exist to make EBM a viable, practicable approach in podiatry? Most agree it is both possible and feasible. However, as Dr. Thoms notes, the methodology is still young and the number of resources available are small but growing. Dr. Armstrong suggests incorporating EBM as a segment of a practice’s overall approach to treatment might be the best strategy. He advocates having a balance where clinicians, especially those who are seasoned, challenge everything they see. At the same time, he notes they should not abandon the important element of experience in guiding their own subtle differences in practice. Dr. Satterfield says incorporating an “all or nothing” approach — trying to back up everything you do with EBM — is not possible given the rigors of daily practice. “I quickly found out that I could not see 60 patients a day and take the time to look up something on the computer for each and every patient,” recalls Dr. Satterfield. “Use the tool wisely and it pays off. Use it for everything and you will get bogged down.” Dr. Thoms concurs, emphasizing that EBM can be a component of a physician’s clinical decision-making. “A lot of people think EBM is going to replace clinician opinion or experience but it really does not. It augments it,” maintains Dr. Thoms. Where the most effort will be needed is injecting EBM into podiatric medicine for DPMs who have already established a practice. Established DPMs in private practice may not be not familiar with EBM or may simply feel they do not have the time to perform the requisite research. “When you are out in practice, sometimes it is difficult to stay up on all the latest information,” concedes Dr. Thoms. “Actually, if we were to try to read all the information that comes out, we would be reading for days. We have to learn how to be very selective in what we read. The approach of EBM lets you be very selective in what you are reading and in how you apply it to your patients in order to give them more treatment options.” “I personally do not have EBM fully incorporated into my practice,” admits Dr. Fishco. “I do have protocols for just about all the common conditions that are seen on a daily basis. I read the literature and make changes in care when appropriate. The main reason that I have not done more is lack of time. Most of us are working in the trenches 10 to 12 hours a day, five days a week at the least. Finding time to carefully evaluate the literature and update treatment protocols is time-consuming.” Taking Advantage Of The Resources On EBM Those who are able to invest the time have a growing number of options. “Established practitioners should attend lectures in which EBM is integrated, read articles and editorials about EBM, and perhaps take a course in EBM,” suggests Dr. Kim. “This will take some investment in time and money, but will be well worth the effort.” Just as the Internet provides patients with a wealth of information on their treatment options, it also provides podiatrists with the tools to find evidence-based data to incorporate into treatment. For example, the Center for Evidence-Based Medicine’s Web site (https://www.cebm.net/) contains a wealth of information and tools to help support physicians in all fields who want to develop a more evidence-based approach. Another great example is the popular PubMed site (https://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed), run by the National Center for Biotechnology Information. This site offers search functionality that can alert you via email when the site updates articles on topics you select. Dr. Armstrong is a big fan of this feature. While Dr. Armstrong concurs that is difficult to “read as much as you should,” he says it takes less than five minutes to set up a PubMed update, which is available on the home screen of www.pubmed.gov. He says podiatrists can search on “hammertoe” or “diabetic foot,” and get weekly e-mail updates on the latest research. “Tools like this make it easy,” he says. “It does the work for you.” Dr. Satterfield feels the most helpful resources are those regarding pharmaceuticals. “Sometimes we get into the habit of prescribing particular medications without checking on efficacy as newer pharmaceuticals are released. Conversely, we are in the habit of always prescribing the newest product without considering that the older ones may have better efficacy,” adds Dr. Satterfield. Keeping up to date on ongoing and forthcoming information on EBM might also include getting involved with professional organizations and associations that are sympathetic to the cause. Current efforts in introducing EBM include special committees of the American Podiatric Medical Association and the American College of Foot and Ankle Surgeons, according to Dr. Fishco. He says the profession is seeing more presentations in seminars that are conducting research to add to EBM. Final Notes With expanding educational and professional resources, and evolving implementation of protocols, one might wonder what else might help foster a wider use of EBM in podiatric practice. “Evidence-based medicine can be mainstream if we teach the concept to DPMs online or at seminars,” says Dr. Fishco. “The APMA or state societies can help DPMs implement EBM by organizing the existing EBM data. It is just too difficult for the working DPM to implement EBM into his or her practice without help. I am sure there are a number of DPMs that are using EBM in their practice. A special committee of these members could organize the current data and help with implementation for the rest of us.” “The first step is to understand what EBM is,” reiterates Dr. Kim. “This involves familiarizing yourself on EBM by reading about it in articles and editorials in print or online, and taking a formal course in EBM principles. The next step is to take this knowledge and attend lectures utilizing the EBM format at conferences covering common topics in podiatry.” Dr. Thoms’ experiences with lectures and conferences have made her a believer in their ability to spread the word on EBM and help practitioners integrate it into daily practice. She suggests those serious about EBM should attend an EBM-specific conference. She says these multidisciplinary conferences offer workshops that are “quite intensive.” Ultimately, this widening collective base of knowledge cannot help but expand the use of evidence-based protocols in podiatric practice. In Dr. Fishco’s estimation, EBM is an extension of what physicians have always done, namely continue looking for ways to improve clinical care. “We should always be looking for a better way of doing things,” he says, “whether it is safer, more effective, less painful, requiring less convalescence, more economical, etc. Evidence-based medicine is a tool that we should be using to make a careful assessment about the way we are doing things. Podiatrists are all in the same boat. We are treating the same problems and we should stick together to benefit from one another as we are the best trained experts who treat patients with disorders of the foot and ankle.” “We must foster a culture of inquiry in our practices and a culture of being open to change,” maintains Dr. Armstrong. “That is the secret. If you do that, you will get better. The profession will get better. We need to accept the possibility that we can get better.”