Evidence-Based Medicine: A Worthwhile Investment?
Prove it. Well, it’s easier said than done when it comes to evidence-based medicine (EBM) in podiatry. In the Diabetes Watch column this month, guest columnist Kathleen Satterfield, DPM, tackles the issue of open amputations versus closed amputations (see page 16). She notes that on this specific topic, “much of the knowledge that we operate under comes from research at other anatomic levels by other specialists.” The lack of EBM is a prevailing issue across the board in podiatric surgery, according to one experienced surgeon and educator. He notes that podiatric surgeons still base most of their procedures on EBM studies that have been done by allopathic surgeons. As another podiatrist points out, there is also no EBM to support the use of orthotics, NSAIDs or “most of what we do for plantar fasciitis.” Those in the know say that shifting to EBM will ultimately provide better choices for doctors and patients when evaluating and comparing different techniques and procedures. They also point out that having more EBM in podiatry can help foster a greater acceptance of the profession within the mainstream of health care. Insurers are also increasingly demanding evidence in regard to the efficacy of a given procedure or modality. Pointing to the use of extracorporeal shockwave therapy as an example, a prominent podiatrist explains that “(Insurers) don’t want to pay unless there is clear and compelling proof.” However, there are considerable obstacles to facilitating a more active role in EBM by podiatrists. Even those who are active proponents of EBM in podiatry admit that it is time-consuming and requires significant effort to reach statistically valid conclusions. Minimizing the potential variables can be difficult. According to one prominent surgeon, in order to have a valid study on injection therapy of the heel, it would need to be predicated on one surgeon doing the procedure with different medications in the same location for the same problem for the same reason. Assuming another doctor uses the exact same methodology and executes the procedure in a similar manner, would you see the same results? “EBM only works if you get the same answers regardless of who tests and gathers the information,” the surgeon emphasizes. Perhaps the greatest obstacle is funding. EBM tends to be more prevalent in the pharmacology realm. This makes sense as most pharmaceutical companies have the wherewithal to support the kind of studies that are necessary for EBM. However, it’s highly unlikely that you would see even remotely close to the same kind of funding for a study of a given podiatric surgical procedure or orthotics. Developing a research mindset in a largely private practice dominated profession may prove to be particularly difficult. The turnout for a session on “Industry Research” at the ACFAS meeting spoke volumes. There were about 12 people in the audience. There have been some positive developments. The ACFAS recently initiated a task force to develop strategies for promoting EBM practice and methodology. One experienced podiatric surgeon also points out that “more podiatric centers than ever” are participating in industry-sponsored FDA studies. Will the results of an evidence-based study change the approach of someone who has over 20 years of clinical experience? As one DPM told me, while EBM would give the profession more credibility, it won’t change “most of what (he does).” Despite the obstacles and the prevailing notion that experience is the best teacher, perhaps EBM will play a renewed complementary role in clinical decision-making, and may even prove to be a valuable safeguard against getting too locked into a certain way of doing things.