Evidence-based medicine

Patient expectations should always be discussed prior to surgery or any other medical treatment because realistic assumptions of a treatment’s outcomes are essential to weighing the options. There is plenty of scientific evidence in the literature regarding more complex issues or this type of daily practice, but there are many cases in which the evidence is not or cannot be used.

The dictionary definition of the terminology ‘evidence-based’ states that a given phenomenon is ‘supported by a large amount of scientific research’ [3]. Presently, we commonly use the term in conjunction with ‘medicine’, ‘clinical practice’, and ‘healthcare’. Sometimes, we cannot be certain whether these words are used appropriately or can be used interchangeably. Evidence-based medicine (EBM) implies the careful and deliberate integration of up-to-date evidence so that informed decisions can be made for superior individual patient care. As such, evidence-based practice (EBP) integrates clinical expertise with current EBM knowledge derived or induced from systematic research in combination with patient preferences. Based on the meanings of EBM and EBP, evidence-based healthcare relates to decisions made at group or population levels [5].

The implementation of EBM in daily practice constitutes a critical and challenging issue for orthopaedic surgeons and sports medicine specialists; however, it is essential to ensure high-quality healthcare at the most optimal costs. Notably, important concerns arise when certain pathologies are not treated according to the best available evidence, and thus not following the idea of EBM.

However, several issues render the EBM model questionable in certain clinical cases. Generally, the level of EBP adherence is relatively low worldwide owing to the lack of EBP competence, lingering misperceptions, lack of support from colleagues and managers, inadequate resources, local physician-driven practices, and the need to maintain professional and political boundaries [2, 10]. On the other hand, although many physicians present positive attitudes towards EBM and its benefits to patient care, even though doing so does not always lead to consistent and high-quality EBP in the field.

Why is the clinical practice not as evidence-based as it should be?

Although the evidence-based literature continues to grow, it is not always feasible for clinicians to stay proficient. Hence, many scientific journals encourage researchers to submit synthesised compilations of this nature because systematic reviews and meta-analyses provide good compendia for clinicians and researchers [6]. But this approach is only one piece in the game. Conclusive reviews are based on well-performed primary research; however, primary research also has space for improvement [7, 8]. Conclusive research is available, and thanks to modern databases, e.g., Epistemonikos as the largest source of systematic reviews, which is helpful for health-decision-making processes. These databases are broadly available and often well-synthesized and translated for daily use in clinical practice guidelines.

The ‘working evidence’ phenomenon refers to the individual clinical expertise that asserts itself as conventional wisdom in local practices. The proponent David Sacket indicated in the article, which was cited more than 20,000 times, that external clinical evidence can inform, but can never replace individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision [9]. This sentiment has led to the rise of the EBP paradigm, which focuses on the individual differences among patients, their expressed needs and the local wisdom of the clinician combined with findings from external evidence literature.

Patient preferences are notably important to medical decision-making. For example, if a patient expresses chronic pain while demanding a surgical solution, EBPs indicating eccentric tendon training as a therapeutic mitigation technique are unlikely to satisfy the patient, as patient compliance is crucial to this process.

Moreover, implementing evidence into the country-specific healthcare systems is sometimes difficult. There is a huge amount of literature on inpatient care after total knee arthroplasty available. However, patients in some countries are operated on an outpatient basis and go home after surgery nowadays. Thus, evidence on treating patients in a hospital is unlikely to be of any help, e.g., the use of any training machines or walking bars in early postoperative rehabilitation.

The successful implementation of EBM requires consistently high-quality communication among stakeholders, e.g., nurses, physiotherapists, physicians and patients, as they are usually not on the same level of information on a topic.

Preoperative education, goal setting, and precautions can serve as examples. Imagine a patient may be inclined to favour total hip arthroplasty if the clinician provides accurate information regarding anticipated low pain levels after recovery, which very often leads to a more active life afterwards. In many cases, this patient would be educated by the surgeon during the pre- and post-operational consultations that deep flexion should be avoided after surgery. On the other hand, the physiotherapist may emphasise the increased risk of hip dislocation caused by excessive adduction or external rotation, whereas a nurse may separately recommend that public transport should be avoided to avoid falling. In such cases, the patient is likely to become very confused based on apparent contradictions. Moreover, the patient’s general anxiety will increase owing to the heavy emphasis on risks and avoidance. If stakeholder education in such cases were to rely on EBM but also on communication, experience and preferences of the patient, the result of a patient being afraid of arthroplasty dislocation would likely be avoided.

EBP implementation

The remaining questions seek to provide an understanding of what clinicians and stakeholders are currently lacking. Is it ‘time’, ‘interest’, ‘knowledge’, or a combination of these? Apart from the necessary academic preparation, the successful implementation of EBP requires practical support, resources and access. Supportive, collaborative relationships and professional confidence are known facilitators of EBP implementation [2]. Moreover, problem awareness mechanisms and the willingness to address barriers to implementation are urgently needed [1]. Clinical leaders must understand and accept the power they are afforded to change both practices and mindsets. Considerable practical EBM knowledge is currently available throughout the healthcare profession, and education is fervently offered worldwide. Nevertheless, the effective embedding of EBPs throughout the industry requires concerted efforts and pragmatic developments to support a real-world dialogue about a combined eminent and scientific engagement with stakeholders [4].

Scientific orthopaedic journals focus on improving research, education and clinical practice by publishing high-quality, methodological research on clinical practice issues with the goal of illuminating both problems and solutions. Nevertheless, researchers and clinicians face some uncomfortable questions regarding the future of EBM. For example, ‘Is all research necessary’, ‘Is every significant finding relevant’ and worth to be implemented and financed in the health care systems?

Because research is only one issue among many in EBM, new ideas and strategies are needed in orthopaedics regarding EBP implementation and the necessary knowledge translations needed for widespread dissemination. Easy-to-read, plain-language summaries should be provided for all stakeholders. When envisioning worldwide guidelines, both regional and institutional adaptations should be considered, and institutional education and clinical leader discussions are the most basic prerequisites.

In conclusion, reading, understanding, interpreting and assimilating high-level scientific medical knowledge is crucial to EBM. However, reading papers will, by itself, not result in good EBPs. Further emphasis is needed on the implementation of institutional frameworks and auditing in this respect, alongside reasonable implementation approaches, stakeholder communications and effect-based post-implementation evaluations.