Autonomous practice or autonomous ignorance? (Editor's Note).

This month, the Journal is dedicated to a single series of articles. But this isn't your typical Journal series. In this series, the authors report on a vast amount of literature, not merely compiling what has been said in the past, but providing systematic reviews.

Derived from intensive group efforts, the Philadelphia Panel's systematic reviews are driven by 2 sets of explicit rules: (1) the roles that guided the authors and their colleagues in selecting published papers for analysis and (2) the criteria of the Cochrane Collaboration, which guided the authors as they critically evaluated existing research. These criteria have become the accepted standard in biomedical research dealing with clinical practice. The Cochrane approach has been used for many systematic reviews, which means that its methods have been examined extensively through peer review. The methods for the systematic reviews being published in this Journal series are no exception.

Although systematic review cannot guarantee error-free results, it can offer a dense compilation of facts and evaluated data. What is most important about this approach, however, is that the method is clearly delineated. Definitions are supplied. We know that the authors are using certain criteria to judge not only the quality of the published research but also the presence of a success or a failure. Some aspects of systematic review may seem to be bathed in the arcane jargon of the research world, but nothing is more "clinician useful" than systematic review and the clinical practice guidelines that may be derived from it.

In the Philadelphia Panel guidelines, we see the power of systematic review. The task that the authors set for themselves is, in their words, "to improve appropriate use of rehabilitation interventions." (1) They are not telling us what is known and what is not known, but what is supported by evidence and what is not supported by evidence. Clinical practice guidelines can have real power and influence only when they are based on data. The guidelines in this issue use a credible approach that is derived from the methods of science but that also takes into account the individual differences of our patients and clients.

Note that these guidelines are not endorsed by APTA, although APTA along with other associations had input into their development. Only time will tell who chooses to endorse the guidelines, who will accept them, and how they can be improved.

Anthony Delitto, PT, PhD, FAPTA, a member of Physical Therapy's Editorial Board, served as Guest Editor and coordinator for this special issue. He has given us insights into the nature of guidelines through his own research and writings. In 1998, when he was Guest Editor of our special series on low back pain (LBP), Delitto (2) wrote:

   The process of producing practice guidelines includes selecting
   multidisciplinary panels of experts; conducting quantitative review of
   existing literature; making judgments on costs and benefits; and,
   typically, endorsing professional associations. On the surface, such a
   process should be looked at in a positive light, because it seeks to impart
   knowledge gained from the peer-reviewed literature to practicing clinicians
   and to change clinicians' attitudes and behaviors and ultimately improve
   patient outcomes. Despite what appears to be a credible and logical
   process, numerous clinical professions have had some difficulty embracing
   practice guidelines in general, and we have certainly seen blatant
   reluctance to accept practice guidelines related to LBP.

Critics of the call for accountability may target guidelines with a zeal that is often reserved for religious fanatics, and Delitto's observation is, in my opinion, still a critical issue in health care. There are still those health care professionals--and not just physical therapists--who view evidence as an encumbrance and systematic reviews as the devil's tool because the guidelines that are derived from them require thought, justification, and dialogue.

Guidelines such as the ones published in this Journal are not perfect documents. They are approximations of what we know and of what aspects of practice can be based on evidence. Randomized controlled trials (RCTs) offer the best possible evidence, and they make powerful systematic reviews and guidelines possible. In an area such as physical therapy--and in rehabilitation in general--it is often difficult to conduct RCTs. Certain aspects of patient management do not lend themselves to RCTs. In fact, of the 5 elements of physical therapist patient management (examination, evaluation, diagnosis, prognosis, and intervention (3)), only intervention lends itself to RCTs, even though all 5 elements can be based on science and can be manifested through evidence-based practice.

Because RCTs are so difficult, we will always have areas that lack evidence, and we will need to find other credible research approaches to supply evidence. Keep in mind that an absence of evidence is different from negative evidence. An absence of evidence is not an excuse to ignore the growing body of data available to guide practice. In the educational arena, any faculty members who fail to introduce their students to systematic reviews and guidelines such as those in this issue should find employment outside of academia. Our profession and our society can no longer tolerate this irresponsibility.

This does not mean that guideline results have to be blindly accepted--or even accepted at all--by faculty members. But if educators do not discuss guidelines, we will be preparing new graduates for autonomous ignorance instead of autonomous practice. The point isn't whether you agree or disagree that the guidelines published in this Journal represent the best possible evidence. The point is that unless you discuss them and relate them to patient management, there will be no evolution of our practice and no accountability.

Not surprisingly, the nature of guidelines is best described by the Cochrane Collaboration. Their description makes it clear to me that many of the criticisms aimed at systematic reviews, guidelines, and evidence-based practice are rooted in ignorance, malice, or financial interests:

   If better decisions are to lead to improved health, then effective
   mechanisms are needed for implementing them efficiently. Forms of care that
   have been shown to do more good than harm should be encouraged, while those
   that do more harm than good need to be discarded. The many forms of care
   which have unknown effects should, as far as possible, be used in the
   context of a research programme to find out whether they help or do harm.

   In addition, if people are to receive care which is appropriate, then
   policy makers and decision makers--ranging from ministers of health to
   individual clinicians and patients--must consider people's needs, the
   availability of resources, and priorities.

   In making decisions about the care of individual patients, for example, the
   results of the reviews must be integrated with the clinician's expertise,
   which has been acquired through experience and practice. The results of the
   reviews must also be integrated with the patient's expertise, which derives
   from their knowledge of their condition (particularly if it is a chronic or
   recurrent health problem), the treatments on offer, and the responsiveness
   or otherwise of the former to the latter.

   If operating in synchrony, these complementary forms of expertise are
   reflected in more efficient diagnosis and in more thoughtful identification
   and compassionate use of the predicaments, rights, and preferences of
   individual patients in making decisions about their care. (4)

Dr Delitto and I look forward to your discussion of the Philadelphia Panel guidelines--in the classroom, in the clinic, at APTA's Combined Sections Meeting, at PT2002, and, we hope, in the pages of future Journal issues.

References

(1) Philadelphia Panel Evidence-Based Guidelines on Selected Rehabilitation Interventions: Overview and Methodology. Phys Ther. 2001;81:XXXXXX.

(2) Delitto A. Clinicians and researchers who treat and study patients with low back pain: are you listening? Phys Ther. 1998;78:705-707.

(3) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9-744.

(4) Cochrane Collaboration. Good decisions about health care. Cochrane Collaboration Web site. Available at: http://www.cochrane.org/cochrane/cc-broch.htm#PRINCIPLES. Accessed September 6, 2001.

Jules M Rothstein, PT, PhD, FAPTA
Editor