This is the proceeding and slides from a talk I gave at the ABVP Symposium in 2015.

GENERATING EVIDENCE IN PRIVATE PRACTICE

INTRODUCTION
“…the practitioner is an essential part of the total research effort undertaken by our profession and, further, that the barriers between academic and practice life should be lowered so as to integrate the various activities we often designate as “academic”, and practice, research teaching and clinical disciplines.” (Rossdale, 1978)

In a prescient and eloquent article published nearly forty years ago, renowned equine veterinarian Peter Rossdale made the case for encouraging research in private practice. Dr. Rossdale, later an advocate for evidence-based veterinary medicine, recognized the benefits of clinical research in practice to individual veterinarians and the profession as a whole as well as to our patients, who have the most to gain from the production of better research evidence and the development of more effective clinical interventions. The barriers between the domains of research, teaching, and clinical practice, and especially the chasm between academic and private practice, waste talent and resources and retard the production of useful research evidence needed to improve the quality of patient care.

The benefits of conducting research in practice include not only the production of more research evidence but of more clinically relevant and applicable evidence. Clinicians in practice are in the best position to recognize the questions and problems of greatest importance to patient care. While basic research and cutting edge investigations of novel phenomena are ultimately critical to the advancement of medical science, the most pressing and immediate information needs of clinicians often go unmet when those most removed from routine clinical practice set the agenda for research.

Research in practice also has the benefit of improving the scientific literacy of clinicians, giving them greater insight into how the foundational knowledge underlying their clinical practices is produced and what are its limitations. Inappropriate use of diagnostic and therapeutic interventions often stems from a failure to fully understand basic principles of epidemiology, statistics, and other elements of the generation and application of scientific knowledge in medicine. Training clinicians as scientists as well as healthcare providers can improve the depth and sophistication of their understanding of research evidence and how it can be most effectively used to provide optimal patient care.

Integrating research into practice can also have direct personal benefits for practitioners. As Dr. Rossdale put it, “we must provide an outlet for the creative faculties…’students trained in high professional standards may have difficulty in applying these standards to practice.’ And it is this challenge which is recognized by every graduate who turns away from practice, disillusioned by his or her inability to find satisfaction in a situation where the means are not justified by the end that is, where the expectations of training are dashed by the reality of practice.” We can recruit and retain the best minds in veterinary medicine, keep then engaged and motivated, and improve the knowledge base of the profession and the quality of patient by encouraging private practitioners to be researchers and teachers as well as clinicians.

PRODUCING RESEARCH EVIDENCE IN PRACTICE
While the current barriers between academic and private practice, and the paucity of research activities among clinicians outside academia, are unnecessary impediments to the production of more and better research evidence, it is true that some differences between these domains are intrinsic and inevitable. The tangible and intellectual resources available in large institutions with access to large patient populations and those clients most motivated to participate in research do allow academics to engage in types of research activity not practical for clinicians in private practice. Studies requiring expensive equipment, specialized expertise and input from researchers outside of veterinary medicine, and either large numbers of patients or patients with rare diseases, cannot realistically be designed and conducted exclusively in private practice.

Private practice veterinarians could still participate in such studies, as physicians often do, under the auspices of projects coordinated and managed by academic institutions or private industry with the necessary resources. If such distributed, multi-center trials were more common and involved patients in primary or private specialty practice, the amount and applicability of the evidence produced would be improved. This could be a practical method of producing research evidence if a sufficient initial investment were made in setting up networks of practices with appropriately trained clinicians coordinated and supported by academic or industry researchers.

However, there are a number of types of useful research evidence that can be produced in private practice with minimal support from research specialists. These vary in how difficult or costly they are to produce, and how much training and research expertise is required of clinician-researchers. And all good quality research conducted in practice does require clinicians to be familiar with the methodological features of the type of research evidence they wish to generate in order to ensure useful and reliable results with minimal bias. The necessary knowledge and skills can be obtained independently from existing resources, but research in practice could be greatly facilitated by more resources and support from academic researchers and better training of veterinary students in the importance of research and evidence-based medicine methods to high-quality clinical practice.

Clinical Audit
Arguably, clinical audit is not really a type of research in that it is not intended to generate new knowledge but to evaluate the effectiveness of clinical practices in a particular setting relative to other settings or to some accepted standard. However, clinical audit generates important information about the success and limitations of practices in a specific setting, which is necessary in identifying important research questions and areas worthy of investigation. It can also be a simple way of generating observations that can stimulate hypothesis generation or the development of clinical questions for future research. And it provides an opportunity to learn about standardized data collection and to set up mechanisms for collecting and handling data that can also be used for original research.

In brief, clinical audit is typically a cyclical process in which one identifies a practice to evaluate and a standard of comparison for the practice, then collects data prospectively or retrospectively to determine the difference between the practice as implemented and the standard. (Figure 1) If necessary, changes are made following analysis of the result and future repetitions of the audit cycle are conducted to assess improvement.

Figure 1. The process of clinical audit (from Dunn, 2012)

The clinical audit process can be used to assess the success or failure of therapeutic interventions or the degree to which the implementation of specific practices are consistent with recommended standards or guidelines. In my practice, for example, we implemented the RECOVER guidelines for small animal CPR (Fletcher, 2012) and then conducted a clinical audit to compare out rates of return of spontaneous circulation and survival to discharge with those reported in the literature. We then reported these data as an example of the impact of the implementation of a clinical practice guideline on outcomes in a private practice, thus adding to the relevant evidence base. (Yagi, 2014)

In veterinary medicine, there will often be no clear gold standard against which to compare the results of audit findings. However, the findings themselves can be useful data not only within the practice but to other clinicians. The results of clinical audits can help in the development of practice standards by showing us where we are now, and they can help identify clinical problems for which controlled prospective research evidence is needed. Clinical audit can also provide clinicians with insight into their own information needs and deficiencies, and with knowledge and experience needed to engage in other research activities. Most importantly, of course, such audits improve patient care.

Case Reports/Series
The type of research evidence private practice clinicians have traditionally bene most likely to produce is the case report or case series. These are descriptions of individual cases or groups of cases with the same clinical problem or subject to the same intervention. Since there are no controls for bias or other sources of error, these reports are appropriate only for suggesting hypotheses to be investigated through controlled research. Case reports and series are low-level, unreliable evidence and should only be used to guide clinical practice with great caution and in the absence of any better quality evidence.

However, such reports are relatively easy to produce, and they provide valuable information about new and uncommon clinical problems or interventions.

Observational Studies
Observational studies do typically involve comparisons among groups of patients subject to different treatments or exposures related to health conditions. They are stronger evidence than uncontrolled case series, but they do not allow for randomization or other important bias control methods, so the conclusions of such studies must still be viewed with some caution and skepticism.

Observational studies can vary from relative simple retrospective analysis of information already collected to complex prospective study designs. Even relatively simple studies assessing the incidence or prevalence of particular health conditions, for example, would contribute significantly to filling information gaps in veterinary medicine. More complex study designs can also generate information about causal relationships between exposures and disease or interventions and outcomes.

Observational studies have particular appeal in private practice because they do not require deliberate, random assignment of subjects to treatment and control groups and the use of placebo treatments, which many clients might be reluctant to consent to. They are often simpler and less costly to conduct than interventional studies, but training and expertise in the relevant research methods is still essential to ensure effective design and execution of observational studies and the production of reliable, useful information.

The development of electronic medical records systems (EMR) has facilitated observational research in human medicine by simplifying the collection and retrieval of data. Properly designed EMR systems in veterinary medicine would make many types of observational research economically logistically feasible for private practice clinicians. Such systems are rare today. However, there are a number of veterinary EMR providers and a fair degree of competition among them, and it is possible that if the capacity to easily collect data and configure such systems for research purposes were widely demanded, manufacturers might be willing to provide these features.

“We are all academics in that we subscribe by our training and our aspirations to scientific objectivity; we are all teachers in that we are anxious to impart our knowledge and wisdom to our colleagues and our successors; we are all practitioners of the veterinary art in one form or another. And each of us have a vested interest in research.” (Rossdale, 1978)

REFERENCES
Dunn, J. Clinical audit: A tool in defense of clinical standards. In Practice. 2012;34:167-169.

Fletcher, D. et al. RECOVER evidence and knowledge gap analysis on veterinary CPR.

Part 7: Clinical guidelines. J Vet Emerg Crit Care. 2012; 22(S1):S102–S131.

Rossdale, PD. Combining research with veterinary practice. Can Vet. J. 1978;19(12):327-330.

Yagi, K. (2014 September ) How RECOVER changed us. International Veterinary Emergency and Critical Care Symposium, Indianapolis, IN.

These are the proceedings and slides for a lecture I gave at the 2015 symposium of the American Board of Veterinary Practitioners.

PRAGMATIC EVIDENCE-BASED VETERINARY MEDICINE IN PRIVATE PRACTICE 

WHAT IS EVIDENCE-BASED MEDICINE (EBVM)?
Evidence-based veterinary medicine (EBVM) is the formal, explicit application of the philosophy and methods of science to generating understanding and making decisions in veterinary medicine. It is often associated with academic research and university or specialty practice. However, EBVM also provides a perspective and a set of behaviors veterinarian in clinical practice can employ to control bias, reduce errors, and manage information more efficiently in general practice as well.

WHAT CAN EBVM DO FOR ME?
In the private practice setting, where limited time and resources and the agendas of our clients constrain our actions, EBVM can facilitate better clinical decision making and improve patient care, aid in managing uncertainty, communicating effectively with clients, and establishing habits to facilitate ongoing learning and improvement throughout one’s career.

The main benefit of employing EBVM techniques is having better information on which to base our clinical practice. When there is good quality evidence to help us evaluate diagnostic and therapeutic interventions, EBVM helps us find this evidence and learn how to use it to inform our decisions. When, as is often the case, the evidence is poor in quality and quantity, understanding this helps us to avoid the risks of unjustified certainty and be mindful of the need for flexibility and lifelong learning in clinical practice.

Better information, and more informed decision making, leads to better patient care. There is evidence from human medicine that the implementation of evidence-based clinical practice guidelines and other EBM tools improves patient outcomes, and this is the goal of EBVM as well.

Finally, EBVM can help practitioners meet our ethical obligations to patients and clients. We have a duty to our patients to provide the best care possible, and EBVM facilitates this. We also have a duty to provide truly informed consent to our clients. Only by understanding the evidence behind our recommendations, and having a clear view of the degree of uncertainty present, can we effectively guide clients in making decisions for their animals.

THE STEPS OF EVIDENCE-BASED PRACTICE
Evidence-based practice involves following a set of explicit steps to integrate formal scientific research information with the individual circumstances of each case to facilitate decision making. The busy practitioner will clearly not be able to execute each step for every problem in every case, nor is this necessary. But by regularly employing the EBVM process, we build and maintain a knowledge base that informs our decisions.

Of course, every veterinary clinician already has extensive knowledge and opinions that inform his or her practice. However, without EBVM, our knowledge base is haphazard and uncritically derived from sources of unknown or low reliability. EBVM allows us to have greater confidence in the knowledge we rely on when making recommendations for individual patients.

These are the basic steps of EBVM:

1. Ask useful questions
2. Find relevant evidence
3. Assess the value of the evidence
4. Draw a conclusion
5. Assign a level of confidence to your conclusion

Asking Useful Questions
Vague or overly broad questions impede effective use of research evidence in informing clinical practices. “Does drug X work?” or “What should I do about disease Y?” are not questions that are likely to lead to the recovery of useful information from published research. There are a number of schemes for constructing questions the scientific literature can help answer. One of the easiest is the PICO scheme.

P– Patient, Problem
Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I-Intervention
Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator
What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome
What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

FIND RELEVANT EVIDENCE
Experienced clinicians typically have opinions on the value of most interventions they routinely consider. Unfortunately, we rarely know where those opinions originally came from or how consistent they are with the current best scientific evidence. And given the constraints of time and resources, practitioners will rarely have the ability to find and critically evaluate all the primary research studies relevant to a particular question. Fortunately, there are sources of evidence that can provide reliable guidance in an efficient, practical manner.

The best EBVM resource for busy clinicians is the evidence-based clinical practice guidelines. These are comprehensive evaluations of the research in a general subject area that explicitly and transparently identify the relevant evidence and the quality of that evidence and make recommendations with clear disclosure of the level of confidence one should place in those recommendations based on the evidence.

Sadly, many guidelines produced in veterinary medicine are not evidence based but opinion-based (so-called GOBSAT or “Good Old Boys Sat At a Table” guidelines). These are no more reliable than any other form of expert opinion. Excellent examples of truly evidence-based guidelines are those of the RECOVER Initiative for small animal CPR and the guidelines produced by the International Task Force for Canine Atopic Dermatitis.

After evidence-based guidelines, the next most useful resources are systematic reviews and critically-appraised topics (CATs). These are more focused but still explicit and transparent reviews of the available evidence on specific topics. Systematic reviews can be identified by searching the VetSRev database, a free online resource produced by the Centre for Evidence-based Veterinary Medicine (CEVM) at the University of Nottingham. Unfortunately, getting full-text copies of these reviews can be challenging for vets not at universities, but there are a number of options depending on where one practices.

Critically appraised topics are also produced by CEVM and freely available on the web as BestBetsforVets. There are a number of other free CAT resources, including the Banfield Applied Research and Knowledge web site.

Finally, primary research studies are a useful source of guidance for clinicians, though they take more effort and expertise to find and critically evaluate.

ASSESS THE VALUE OF THE EVIDENCE
The most challenging part of the EBVM process for vets in practice is critical appraisal, learning to identify important limitations in published research study that affect how confident we can be in the conclusions and how relevant they are to our patients. There are resources available to teach these skills, and hopefully this will become more common in veterinary colleges, but for most practitioners pre-appraised evidence, such as guidelines and systematic reviews, will be more useful.

The clinician still has an important role, however, in determining the relevance of research evidence to individual patients. The details of a patient’s medical condition, the values, goals, and resources of the owner, and the expertise and resources available to the veterinarian all determine the degree to which a particular conclusion based on formal research is applicable to a given patient. The role of EBVM is not to replace clinician judgment with automatic reliance on published research but to ensure the clinician has the best available information and understands clearly what is known and not known when tailoring the evidence to the needs of individual animals.

DRAW A CONCLUSION
Ultimately, the job of a veterinarian is to guide the client in making decisions about care for their animals. When the clinician is aware of the existing evidence and its limitations and clearly appreciates the degree of uncertainty, then he or she can best help the client to understand their options. Making evidence-informed decisions and clearly communicating with clients about the needs and choices for their animal is the core of clinical veterinary medicine, and this is what the tools and methods of EBVM exist to support.

ASSIGN A LEVEL OF CONFIDENCE TO YOUR CONCLUSIONS
Often, the relevant research evidence is incomplete or flawed, and sometimes there is little or no such evidence applicable to a given patient’s needs. EBVM is still useful in this situation, because it allows us to clearly, systematically identify and communicate the uncertainty inherent in our work.

It is also important that we openly discuss with clients our use of evidence to inform our recommendations. Research has suggested that clients want to be told about the uncertainties involved in the treatment of their animals, and that discussing this does not reduce their confidence in their veterinarians. Clients also identify truthfulness as their highest priority in communication with their vet. By explicitly discussing our process in identifying and evaluating relevant evidence, we enhance our clients’ understanding of the role we play, and we help them to appreciate the value of our expertise, not only the products and procedures we sell.

EBVM AND THE PRIVATE PRACTITIONER
The job of the private-practice clinician is to be informed about the research evidence relevant to their patients’ needs and to think critically about this evidence and the uncertainty it contains. It is also the role of practitioners to communicate clearly with clients about this information and guide them in making informed decisions. Ideally, general practitioners can also contribute by sharing what they learn in applying the EBVM process. Critically appraising individual studies or synthesizing the literature on particular questions will create useful information that can then be shared with colleagues.

Properly applied and with adequate support, EBVM can enhance the quality of information supporting the decisions and recommendations of vets in clinical practice. This not only reduces stress and wasted effort for veterinarians but improves client communication and patient care.