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Some Thoughts on Evidence-Based Practice and Decision Making

Dr. Tricia Greenhlagh has been someone who has immensely influenced my thinking. She is a professor of primary care health sciences at the University of Oxford, and she wrote a great little book called “How to Read a Paper: The Basics of Evidence-Based Medicine.” (1) She now also adds a blog to her list of accomplishments (http://blogs.biomedcentral.com/on-medicine/2015/11/03/extending-study-evidence-based-medicine/). I like very much her take on the challenges of evidence-based medicine.

In her book, she makes the following statement: “critics of evidence based medicine might define it as: ‘the increasingly fashionable tendency of a group of young, confident, and highly numerate medical academics to belittle the performance of experienced clinicians using a combination of epidemiological jargon and statistical sleight-of-hand.’” (1, p.3) To a degree, though she wrote those words in 2001, they remain true today; there is still tension between the vicissitudes of EBP and the needs of practitioners. This may arise because clinicians may feel they are being belittled, that it suggests that practitioners were avoiding literature, or were unable to understand it; that is, that they were illiterate in one sense. So, Dr. Greenhalgh looks at how decisions related to practice may be made. She lists four methods that are common, and which I think we all can recognize.

  1. Decision making by anecdote: We see this fairly commonly in both chiropractic clinical training and in clinical practice. A problem arises and the chiropractor in charge remembers some similar situation from his or her past experience and then relates that to those in attendance. Or perhaps you had a bad reaction to some intervention and swore you would never offer it to your patients. This despite the fact that such bad reactions are incredibly rare.
  2. Decision making by press cutting: What this refers to is us following the news and modifying our clinical behavior after we read some new news report. Understand, our patients and the public do this all the time, right? They read that using butter may confer some benefit, so they begin using butter (I am making this up, mind you). We also do this. I have seen people suggest clinical change based on some news report. I myself almost always try to get that news report, to see what it really says, to see if it can support its claim. Often it cannot. I refer to this as bad science reporting.
  3. Decision making by expert opinion: one of my old bosses used to refer to this as “reference to authority.” That is, we do something because some leader has said we should do it. This may also involve doing it because some consensus statement somewhere says to do it.
  4. Decision making by cost minimization: We take cost into account in making a decision. This is less a problem in chiropractic than in general medicine, since our interventions are not costly and are not resource hogs.

But in the end, we should use many tools for making decisions and one of those is evidence-based practice itself. It is just another set of tools we can use, but one that illuminates information that may benefit our patients.



  1. Greenhalgh T. How to read a paper: the basics of evidence-based care. BMJ Books; London, UK; 2001

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