Is Evidence-Based Practice becoming “Fear-Based Practice”?

Is evidence based practice becoming fear based practice now? What I mean by that is something I want to expand on this video because it's a trend I've noticed for a while. It's been accelerating the last couple of years. It really seems to be accelerating in students I talk to. And I think it ends in a bad place for our patients and we're not really talking about it. So I wanted to just put this out there and see what other people think. To start with this, I want to illustrate this with a little story of when I was young, when I was a teenager. Those of you who don't know, I'm a second generation chiropractor. I'm very fortunate to have been exposed to chiropractic my whole life and I always wanted to be a chiropractor. However, my parents, thinking quite smartly, thought, let's make sure Chris isn't just doing this because it's the easy path. And they encouraged me to look at other professions. And I did seriously consider medicine for a couple years. I was really looking at it, really thinking about it. I had this really naive idea of being a chiropractor and a GP at one point, to have a foot in both worlds and be in debt till I was 50. Luckily, I was taught out of that. That would not have been a good path, not for me anyway. But I can remember the very day I decided I'm not going to do medicine. And that was an afternoon spent shadowing a GP who's a consultant GP in an outpatient clinic in a hospital. And one afternoon with this guy was enough to make me go, I never ever want to end up like you. I never wanted to be there. The guy was burnt out, jaded, didn't like his job, moaned about the NHS every chance he got, didn't seem to care about his patients very much, was just trying to get through the day. And I walked home going, no, even if there's a 1% chance of that, I'm not taking that risk. And I stand by that decision, especially learning what junior doctors go through. Credit to them, I couldn't hack that. But anyway, the example that really stood out to me was he had a patient who came in with a very swollen knee and they'd had some tests and he was just kind of checking in on how they were doing. I don't really remember much about the knee. Cause what stood out to me is in the middle of the conversation he said, oh, by the way, your brain scan came back, that was fine, so don't worry about that. And the patient went, oh, okay, good. And then finished the appointment. Off they went. And after the patient left, I said, what's with the brain scan? What was that about? And he went, oh, well, she was getting headaches. I was like, oh, okay. We're like, you worried it was a tumor or something? He's like, no, no, she just wasn't drinking enough water. But I have to send for the mri, because if I don't, and it's the million to one chance it isn't that, then I could get suddenly sued. So I sent it for that MRI and I wasted a bunch of money on the NHS because otherwise I'll get sued. And then moaned about the NHS some more. And that's a really good example of what's called defensive practice, where the practitioner makes decisions out of fear of what the options might impact, how they might impact on them. So the fear of being sued meant he recommended this patient have an MRI that he knew they didn't need and they didn't need. Now, it'd be lovely if we could scan everything all the time, but as we know from the research, actually sending for MRIs, a brain scan is one thing. Imagine if that was a spinal mri. Patient picked up on the report, some scary sounding language and that put them off moving. It got them really tensing up. We know that negatively impacts patients, especially when it's explained badly. So we need to be really, really careful of that, that we're not just sending patients out for scans that they don't need. For example, now the evidence is now saying that we shouldn't be doing that. It's just caught up with things, which is really good. However, that does mean sometimes we're not SEN patients, the scans that they should have, because we're afraid of the impact that scan might have. So that's something that we need to consider. The bigger issue, though, is that I'm seeing this in more and more chiropractors now making decisions that are driven primarily by their fear of getting sued, their fear of having a GCC complaint. Often this is something, the case that we see with new graduates and younger students all the time. They're really worried about, oh, what if this happens? What if that happens? But I'm seeing it with experienced practitioners now, ones who, you know, don't adjust the neck unless they have to because they're worried about the risk of stroke, even though we know from the research it's not a causative relationship. It couldn't be clearer than that. But they're not Doing it because they're going, what if, now if there's genuinely no benefit to doing a procedure, fine, I get that. But the problem with that narrative is you won't start to look for benefits, you'll start to look for negatives. If you're worried about that, you spot things all the time. If you know anybody who's a little bit paranoid, maybe they got a little bit paranoid over the last couple of years, you know what that's like. They start to spot patterns that maybe aren't there. And that can happen with us. That's what happens when evidence based practice turns into fear based practice. Or maybe because the research suggests that, you know, most people get better with back pain on its own, it doesn't. That research actually says they get back to work one year later. Nine times out of 10, that's not very reassuring. But we go, oh well, maybe we shouldn't be treating them or maybe we should treat them less. And out of fear of over treating, we then under treat. The patient gets substandard care. And that's something that we need to be really, really careful of. Because this is something that is something we all go through that as new graduates. I get that. But I'm seeing it in experienced practitioners more. The fear of a complaint, the fear of the patient getting the wrong end of the stick, the pitfall fear of the patient being unhappy with the result means that we don't even entertain it. And that is going to lead to substandard outcomes. And that's where non evidence based practitioners are going to pick those patients up and do much, much better if they're not afraid to do the thing the patient needs because they're not worried about putting their own needs in front of the patient. It's actually where evidence based practitioners can become doctor centered without realizing. Now I'm not going to be harping on about non evidence based practitioners. It's not really what I choose to on focus, focus on here. You know, vitalism is a whole other issue. But as an evidence based practitioner myself, what I really want us to think about in this camp is to think about where we can become Dr. Centered because it's easier to throw stones at the other side than it is to look in the mirror and go, are we as patient centered as we really want to be? Are we holding ourselves to that standard? So my challenge for you would be to think about yourself. Think about where you may be making decisions out of fear, where you may be affecting choosing a certain path for a patient or recommending a certain care, not because it might be the best thing in their interest when you remove finances and inconveniences and all of that stuff that we shouldn't factor in. Or you may be, instead of doing that, going, okay, well, I'm afraid that if I do this, that might happen. Now, a little teaser for next week. Next week's video. I'm going to tell you how to cause corda requirement without getting sued because this is something that happened to me. I had a patient who had cauda equina right after I treated her, ended up absolutely fine. So keep an eye out for that next week because really, as I'm sure you're expecting for me to say, it comes down to communication. It comes down to making the right choice for the patient in that moment. But if you're worried about this stuff all the time, you're worried about your license, you're worried about the gcc that will impact your care, that will impact your patients. So have a think about that. That's the challenge for this week. Next week, I'll tell you how I called cord or required and didn't get sued. So keep an eye out for that one and chat soon. Take care, Gu.