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What is Evidence-Based Clinical Practice?

Palmer's strategy for focused curricular change to improve patient care
"Chiropractic is science," states the first Chiropractic Brief in D.D. and B.J. Palmer's book, "The Science of Chiropractic: its Principles and Adjustments," in 1906. Of course, this book and subsequent others went on to say that chiropractic is much more than science, but at its core it can be defined as a healthcare science with a unique philosophy and manner of delivery. The challenge for contemporary chiropractors is integrating the ever-growing body of scientific evidence with their own clinical expertise and experience. Evidence-based clinical practice (EBCP) is a powerful tool to accomplish this, and Palmer College is at the forefront of integrating EBCP into the Doctor of Chiropractic curriculum.
What is evidence-based clinical practice?

Evidence-based clinical practice grew out of a movement started by a group of healthcare educators at McMaster University in Hamilton, Ontario, Canada, during the 1980s, said Dana Lawrence, D.C., M.Med.Ed., M.A., senior director of the Center for Teaching and Learning at Palmer and a leader in integrating EBCP into the curriculum. “These physicians observed that a gap had developed between what occurred in clinical practice and what was obtainable in reports of clinical research,” he said.

“Essentially, clinicians could not stay abreast with new research because it was being produced so fast,” Dr. Lawrence added. “Consequently, they were not putting the most current information into practice. Evidence-based methods were designed to bridge this gap.” The concept of chiropractic practice changing as evidence emerges is not new. Palmer Professor Virgil Strang, D.C., wrote that B.J. Palmer made radical changes in his thinking and practice. He offers a telling quote from B.J. Palmer: “I have been a constant research student, seeking further light in newer and better explanations of solutions of unknown problems hidden in our new science.”

EBCP is made up of three co-equal components, Dr. Lawrence explained: best research evidence, clinical expertise, and patient preferences and values. An important component of EBCP is that it incorporates the skills of the doctor. “The practitioner’s clinical expertise is integrated with the best available external clinical evidence from systematic research,” said Dr. Lawrence. “EBCP relies heavily upon the practitioner’s past clinical experience. The misperception is that research evidence trumps the clinical expertise component in EBCP. The reality is that they are co-equal. EBCP is a set of tools that allows you to find and use information when you’re confronted with a patient and their concerns.” EBCP is helping Palmer graduates successfully navigate the ocean of information available to today’s healthcare practitioners.

Dr. Lawrence stressed that EBCP is not a “cookbook” method of practice. “It is the process of actively seeking support for and improvement of chiropractic clinical practice through the integration of the best available research, combined with clinical expertise and patient values.” Taking patient preferences in terms of personal values, concerns and expectations into consideration is an essential step in the EBCP process.

The history of EBCP at Palmer

Known for its well-rounded education in the science, art and philosophy of chiropractic, Palmer has always sought ways to enhance its education in all three of these key components of chiropractic. “Palmer is committed to providing the best education possible to future doctors of chiropractic,” says Davenport Campus Provost Dan Weinert, M.S., D.C. “An important component of this process is to enhance our students’ ability to think critically and to incorporate new knowledge about how to deliver high-quality patient care.”

With this goal in mind, Palmer applied for a grant from the National Institutes of Health, National Center for Complementary and Alternative Medicine (NCCAM) in 2006 to aid in the College’s ongoing efforts to further develop faculty, create a more evidence-based curriculum and expand research efforts. In November 2007, the College received notice of a grant award from NCCAM to expand evidence-based practice across the College. The initial award was $110,000, with an option for an additional three years at a total of approximately $750,000, which Palmer has received since then.

The effort began with an assessment of attitude and knowledge among faculty and students about evidence-based clinical practice. “This assessment provided a foundation for developing training programs to assist faculty in incorporating research findings and evidence in courses throughout the curriculum,” said Cynthia Long, Ph.D., director of research for the Davenport Campus and principle investigator on the NCCAM grant.

Implementing a “train-the-trainers” model

From the beginning, Palmer’s emphasis on EBCP was to “train the trainers” by developing a small cohort of faculty to undergo intensive training and then start training other faculty members. “During the first year of the grant, starting in the summer of 2008, we selected 12 classroom faculty from across the curriculum who began training with Dr. Dana Lawrence as the facilitator,” Dr. Long said. “Then in the second year, starting in the summer of 2009, we began training eight faculty clinicians, with Ian McLean, D.C., DACBR, director of Clinical Radiology for the Davenport Campus, and John Stites, D.C., DACBR, director of Community Clinics on the Davenport Campus, as facilitators.” The three facilitators had received training in teaching evidence-based practices at McMaster University prior to teaching EBCP concepts to Palmer faculty members. The classroom faculty revised their course syllabi to incorporate EBCP during the second year.

One of the highlights of the training program, Dr. Long said, is an intensive, two-day workshop at the University of Iowa, one of Palmer’s partners in the grant along with Thomas Jefferson University. In addition to the initial cohort of 20 faculty members and others on the Davenport Campus, five faculty members from the West Campus and two from the Florida Campus attended this workshop in 2010. And in 2011, nine faculty members—including four from the West Campus—attended the week-long McMaster University program in EBCP.

Additional faculty training has been conducted at faculty in-services over the past several years, and a series of EBCP presentations has been delivered through the Center for Teaching and Learning. Training has now become more organic, Dr. Long noted. “Faculty are mentoring each other in pairs or small groups on how to incorporate EBCP into their classes. We’re also actively working on bringing EBCP training to the West and Florida campuses,” Dr. Long said. “We hope to soon be able to record sessions and post them on our EBCP website along with the PowerPoint presentations from the sessions.” Adds Dr. Weinert: “The bottom line is that Palmer is better preparing students to be critical consumers of information, which, in turn, allows them to be better doctors.”

Scholarship is key

Scholarship has been an important component of the EBCP educational process at Palmer over the past several years. Palmer faculty members have been submitting articles to JACA (Journal of the American Chiropractic Association) for an ongoing section called “Evidence in Action.” (To read the articles in full, go to JACA Online at www.acatoday.org/level2_css.cfm?T1ID=34& T2ID=219.)

In addition, nine abstracts about EBCP from Palmer faculty members were submitted, and all were accepted as platform presentations at the March 2011 ACC-RAC (Association of Chiropractic Colleges Research Agenda Conference). This was, by far, more than any other chiropractic college. Palmer faculty members also presented EBCP workshops at ACC-RAC and at the College’s Davenport Campus Homecoming in August 2011.

Dr. Long also presented a session at the International Association of Medical Science Educators in June 2011 about how Palmer is using the evidence model for basic to clinical sciences throughout the curriculum.

EBCP in action: Dr. Lia Nightingale in biochemistry, nutrition
Lia Nightingale, Ph.D., incorporates EBCP into her classes.
Dr. Lia Nightingale in front of projector screeen

Lia Nightingale, Ph.D., assistant professor in the Physiology / Biochemistry Department on the Davenport Campus, was one of the EBCP classroom faculty members, and she has been teaching evidence-based clinical practice in Biochemistry 1 for the past two years. She also has integrated EBCP into Nutrition, Toxicology and Clinical Nutrition.

“In Biochemistry 1, I spend the entire second week of the trimester teaching the three parts of EBCP—current best evidence, clinical expertise and patient values—focusing on the current best evidence,” Dr. Nightingale said. “We have discussions on the best types of evidence, how to critique an article and how to interpret the results. Their class project is to find, critique and interpret an article based on a clinical question that interests them.”

In her Nutrition, Toxicology and Clinical Nutrition classes, the focus of the EBCP component is on finding and using reputable sources and interpreting the results, just as in Biochemistry 1, Dr. Nightingale said. “The project in Toxicology uses actual deidentified patients from the Academic Health Center clinic who are taking multiple medications and/or supplements,” she added. “Each group must use Dynamed and Natural Standard from the library databases, as well as their textbook, to determine the drug mechanisms, pharmacokinetics, possible interactions and patient recommendations. My job is not to hammer information down their throat, but to teach them to be resourceful and to critically evaluate information.”

Using EBCP in Biochemistry 1 has “helped transform a structurebased chemistry course into a healthcare-related chemistry course,” Dr. Nightingale said. “For example, instead of just lecturing about the process of making trans fats, I now incorporate recent evidence about the risks of consumption, such as the findings that consuming as little as 2% of your daily energy requirement from trans fats can increase the risk of heart disease by 230%, Alzheimer’s disease by 140% and prostate cancer by 121%.”

In Toxicology, she uses EBCP to focus on the “number needed to treat,” or NNT, for both medications and supplements. “For example, 67 people need to be treated with statins for four years in order for one person not to have a heart attack or stroke, vs. nearly every person treated with antibiotics for a urinary tract infection to improve (NNT=1.65). These numbers help put another light on the risk/benefit analysis and give students another tool to use.”

Student feedback on incorporating EBCP into Biochemistry 1 has been overwhelmingly positive, Dr. Nightingale said, both formally and informally. “I’m finding that our current students are much more versed in EBCP and article appraisal on entrance to Palmer than they were two or three years ago.”

Since she had been teaching the Nutrition and Toxicology courses for just six weeks at the time this article was prepared, her student feedback was informal, but it was also favorable. “I have especially seen a change in the Toxicology students,” she said. “They seem much more confident that they will be able to have the tools to navigate through the vast information related to medications and supplements and be able to give their patients correct information backed by evidence that they have found, not by what some companies try to pass off as evidence.”

EBCP in action: Dr. Ron Boesch in the Palmer Chiropractic Clinics
Dr. Ron Boesch pointing to dry erase board

Evidence-based clinical practice has been incorporated in a number of the courses within the clinic division, said Ron Boesch, D.C., assistant director of the Academic Health Center and professor. “The Case Correlation course, for example, has class activities during which students use the ‘Ask, Acquire, Appraise, Apply and Assess’ techniques of the evidence cycle. There are pieces of the process laced through all of the clinic courses.”

With eight faculty clinicians formally trained and others learning the process informally, “the clinicians are able to do EBCP on the fly with interns and patients,” Dr. Boesch added. “In the clinic setting, we’re able to demonstrate to students how to decide when it’s appropriate to use EBCP to enhance care for a particular patient, and then how to use the tools efficiently. In the radiology area, the case types that are given to the students use EBCP with disease processes.”

While students, clinicians and patients benefit from the use of EBCP in the clinics, it’s the clinic patients and future patients of students learning this process who will benefit the most, according to Dr. Boesch. “The efforts help to model lifelong learning and how to systematically approach this process of EBCP so that it is patient centered,” he said. “This gives the intern the ability to provide the best care for patients now and after they have graduated. It benefits the patients because they receive care that is specific and tailored to their needs. This has been an exciting time for us to learn and teach this component of health care. It will only strengthen chiropractic as a profession and provide the best possible care for our patients.”

Research education component

Another component of the NCCAM funding for expanding EBCP across the College is expansion of the Research Honors Program. The Research Honors Program provides students in the D.C. program with an opportunity to experience research firsthand by designing and completing a faculty-mentored research project.

The funding has enabled the Research Honors Program to be offered to students on all three campuses. A regular discussion forum provides students and faculty mentors in the program, or others interested in the program, with an opportunity to share their research ideas, ask questions about how to get involved, gain experience with the application and research process, and share progress on research projects with other members of the program.

Additionally, a research seminar series for students has been established on the Davenport Campus.

What’s next for EBCP at Palmer?

The educational culture at Palmer has changed over the past three years because of this initiative, said Dr. Lawrence. “It’s gone very well. We’re seeing faculty embrace this across the spectrum and on all three campuses. The culture has definitely changed; not only faculty but also students are talking more in evidence-based terms both inside and outside the classroom. They realize that evidence is not just the literature, it’s also clinical expertise and experience.”

As of the summer 2011 trimester on the Davenport Campus, there were 17 courses in which faculty were formally incorporating EBCP into the syllabi, including the first trimester Foundations of Evidence-based Clinical Practice course, Dr. Long said. The intensive training sessions held each fall at the University of Iowa will be open to all faculty members from all three campuses beginning in the fall of 2012. “We want 10 percent of our faculty on each of our campuses to have gone to the McMaster University program or the University of Iowa program by the end of 2015, and with four faculty members from the West Campus having attended the McMaster University program in June 2011, they are close to that goal already,” Dr. Long said. “In the next year or so, this 10 percent will teach more and more faculty members, coordinated through Dr. Lawrence and the Center for Teaching and Learning.”

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