By Jonathan C. Johnson and Andrew D. Fisher
The internet and social media forums of which have become our greatest ally have begun to transform into an equally great adversary. This system seems to be designed and masterfully perfected to allow for experts and novices alike to come together and discuss controversial topics, while promoting growth, research, and self-reflection. It appears there is a split and factions of groupthink and staunch supporters of one camp or another are building walls.
While this is not new to our generation or any generation for that matter, the abundance of information and ease of which it can be dispersed and retrieved has continuously plagued our generation in a grandiose manner. Given the broad application of this issue, the focus is placed on prehospital and combat medicine, and more specifically in relation to the recent re-emergence of the term evidence based medicine (EBM) within prehospital social media forums. The term EBM at times may be used inappropriately and there may be a poor understanding of the role that anecdotal evidence plays in that hierarchy.
As many of us know the term itself originated in the early 1990s and its means; a conscious and reasonable use of current, best scientific evidence in making decisions in the treatment of each individual patient. It is the conscientious, explicit, judicious, and reasonable use of current best evidence in making decisions about the care of individual patients. In this context, it is nearly impossible to argue against its use. The problem is that it by definition reliant upon the assumption that there are sufficient studies and properly collected evidence to address the problem sets that a member of our profession is going to encounter. Furthermore, it presumes that the members of our profession are equipped with a sufficient amount of time necessary to read and analyze such studies and collected data prior to encountering it in their current work environment.
To really understand and use EBM to the fullest, one must know the EBM Triad – 1. Individual Clinical Expertise, 2. Best External Evidence, and 3. Patient Values and Expectations. I, Andrew Fisher having knowledge of the triad haven’t always given clinical expertise a fair shake at times, or at least it may not appear that I am. When I often take someone, I consider a subject matter expert at their word.
This is where the second of the EBM triad comes into play, experiential knowledge, or clinical expertise. Clinical expertise is not, as it is often depicted, a counter-argument to EBM. It is rather a complementary and inherent piece of the approach that all members of our profession must utilize in their field of expertise. This is not an excuse to blatantly and blindly abandon published studies and clinical practice guidelines (CPGs). Instead, it is a means for the members of our profession to use the third piece of the prehospital and combat medicine treatment triad.
There are two types of experiential knowledge tacit knowledge (a kind of knowing-how) and practical wisdom (or understanding of the underlying issues). Tacit knowledge represents not only the stored knowledge but also the ability to expand that knowledge. Practical wisdom comes from Aristotle and the word “phronesis” and means “knowing the right thing to do in a particular circumstance through understanding the circumstance rightly, knowing what matters, and effective means-end reasoning to bring about what matters.” This requires the processing of experiences, as well as the contextualizing of experience within an appropriate and applicable framework.
Clinical knowledge is gained case by case, patient by patient. In order to use experiential knowledge, as an argument, this experience must be more than just seeing or doing something X number of times. There must be some follow through with the patients and cases that are encountered. Experiential knowledge also uses the available data to incorporate into their practice.
This allows one to manipulate and adapt the CPGs they have studied and implemented throughout their careers in order to ensure their patient receives the appropriate and necessary care they require. Regardless of the availability of traditional and tested tools and treatments the CPGs are based upon.
Experiential knowledge is most notably displayed in the form of anecdotes and vignettes that have become both glorified and villainized in any number of today’s forums and social media outlets. It is inherently the most dangerous of the three pieces as it is the most subjective of the three. Experiential knowledge is the subjective feelings and beliefs of the provider themselves. It would be foolish to disregard this piece of the triad simply because we have yet to be able to fully grasp its worth.
Now that the three pieces of the triad have been outlined, the next step that is instinctively sought is to linearize the approach and lay them out in a numeric and orderly fashion placing a magnitude of value upon each of the EBMs. I caution against this approach as it is counter to the more appropriate non-linear approach necessary to address a complex problem. Instead, I urge us all to allow them to remain as three pillars of the triad of treatment for the prehospital and combat medical provider.
It is appropriate that we treat each area of the EBM Triad with deference and an appropriate amount of skepticism. By openly accepting that each pillar has its flaws we are then able to apply the triad effectively and our profession and more importantly our patients remain the focus and as a collective, we all reap exponential benefits.
Ironically this proposed approach brings us right back to the original epistemological process in which EBM is based upon. Where we continue to look at 1. The philosophical analysis of knowledge and how it relates to truth, belief, and justification 2. The various problems of skepticism 3. The sources and scope of knowledge and justified belief and 4. the criteria for knowledge and justification.
More importantly, though it provides a non-linear approach to the complex problem set we are confronted with and minimizes the divide amongst our profession which has begun to distract us from focusing on the true problems at hand.