What do you do when you're baffled by a clinical problem? How do you deal with an unfamiliar situation? Where do you learn what to do?

Journal editors and researchers would like to think that you turn to quality, peer-reviewed journals for the latest and best evidence. However, the evidence suggests something different. In a systematic review, Zadro et al1 reported only about half of physical therapists' (PTs') treatment choices for musculoskeletal conditions were based on evidence. Whiteley et al2 surveyed more than 2000 sports and musculoskeletal physiotherapists for the source of their most recent change to clinical practice. While PTs indicated speaking with colleagues was helpful, attending short continuing education (CE) courses was the principal source of new information.2

Most states require some type of CE units for licensure renewal; subsequently, CE might be a practical solution for keeping current. We have all experienced wonderful CE courses with knowledgeable, engaged instructors who helped us employ new techniques. Unfortunately, we also know that not all courses are equally beneficial. Before spending your precious time and money on a course, you want some assurance of quality and depend on state bodies that approve courses that confer CE units to ensure that quality. There is an inherent trust that CE instructors objectively present evidence in support of their techniques. Are you confident that your CE course is based on unbiased evidence? In a systematic review of musculoskeletal physical therapy CE courses, Peterson et al3 found that less than half of the interventions taught (47.3%) were supported by clinical practice guidelines or systematic reviews. They also noted that course descriptions often distorted outcomes outreaching prevailing evidence.3 Whiteley et al2 contend that some courses promoted as evidence-based may cherry-pick only favorable supportive research. The hands-on learning and guidance from CE courses, important to upgrading clinical skills, may not be the best method for clinicians to integrate the latest research.

Reading medical journals has been shown to be the most beneficial option to stay current, improve knowledge, and advance practice.2 Peer review provides quality assurance that published research is credible. If reading peer-reviewed medical journals is the best way to gain new clinical information, why is this so infrequently used by PTs? Many obstacles exist. Researchers write papers to be read by other researchers who will be reviewing and deciding on publication of their work. Consequently, researchers may place less emphasis on clinical implications. A national survey of Portuguese PTs found that the most important barrier to using evidence in practice was insufficient time, closely followed by an inability to apply research findings to the unique characteristics of their individual patients.4 Work overload and lack of time were also noted by Park et al5 along with a lack of organizational support, deficiency in understanding evidence, and an inability to search for study articles. Ferreira et al4 noted that PTs working in independent practices were 2.4 times more likely to indicate a lack of information resources and research skills as barriers to utilizing evidence in practice. Fortunately, many clinicians reportedly were interested in learning or improving their skills needed to incorporate evidence into practice and to increasing the use of evidence in the practice.4

How do we overcome these barriers to evidence-based practice? This is not just the individual clinician's dilemma. Using evidence to inform practice is a complex matter and cannot be relegated to an individual clinician. Dannapfel and colleagues6 investigated the actual conditions that support use of research by Swedish physiotherapists and identified individual, organizational, and extra-organizational factors that facilitated using research in clinical practice. At the individual level, having a positive attitude and a strong motivation to use research clinically was necessary. Having had some experience with research competency in assessing research studies was deemed important. Evidence-informed practice at the organizational or workplace level requires leadership support, organizational culture, research-related resources, and knowledge exchange. Active encouragement by leadership and management was considered essential to support research use. An organizational culture that promotes learning and research competence in professional development activities provides favorable circumstances for research use. Research-related resources included access to research, databases and technology, financial support for resources, and, importantly, time to apply research findings. Knowledge exchange requires opportunities for discussion and reflection. Finally, extra-organizational support includes evidence-based practice guidelines, participation in meetings, networks, and conferences, as well as involvement in academic research and education.5

Evidence-informed clinical practice is the combined responsibility of clinicians, managers, and researchers. Next time you ask for a colleague's opinion, clarify where their information comes from. Was a CE course careful to explain where there was and was not unbiased evidence to support the technique? Did the facility where you work provide access to journals or databases? Did the journal article you consulted provide you with an adequate explanation that translated their findings into practical clinical applications? In every aspect of our profession, we need to foster our collaborative efforts to attain the goal of improving evidence-informed practice. Let's get busy!

Cynthia M. Chiarello, PT, PhD

Editor-in-Chief

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