Professional practice · Method

Everyone says they practise it, and the measurements say otherwise: in studies of practice, only one treatment in two is among the recommended ones. This article does not argue for EBP; it describes what EBP actually demands, what it costs in time, and where to start.

What is EBP, and what is it not?

The most common confusion is not about substance, it is about scope. EBP is often understood as “applying what the study says”, which is exactly what its founding text rules out.

The definition, word for word

The 1996 editorial sets out a definition in two parts. First part: the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Second part, and it is the one that gets forgotten: the practice means integrating individual clinical expertise with the best available external clinical evidence from systematic research¹.

The word that carries everything is “integrating”. Neither the evidence alone, nor the experience alone: their composition. Evidence without clinical expertise produces mechanical application to a patient who is not the patient in the study; expertise without evidence endlessly reproduces what was learnt at one point in time.

The misreadings to rule out

Where does practice actually stand?

There is a measurement, and it is uncomfortable. It has the merit of shifting the debate: the question is no longer whether to practise EBP, but why convinced professionals do not manage it.

The concordance review

Zadro, O'Keeffe and Maher searched seven databases up to April 2018, crossing terms for “professional practice” and “physiotherapy”, and retained 94 studies quantifying physiotherapists' treatment choices in musculoskeletal conditions, through surveys, chart audits, billing audits or clinical observation. Results are reported as medians and interquartile ranges, separately for surveys and for audits².

The authors' conclusion is blunt: many physiotherapists appear not to follow the guidelines when managing musculoskeletal conditions, and there is considerable scope to increase the use of recommended treatments and reduce the use of non-recommended ones².

One methodological point is worth noting, because it matters for what follows: the “no recommendation” category is the largest, at 81 % in surveys. Much of what a physiotherapist does is neither recommended nor advised against: it simply has not been evaluated. That is where clinical expertise does the work, and it is also where we tell ourselves the most stories.

Reading time, measured

The reference survey on behaviour dates from 2003 and covers 488 physiotherapists who were members of the American association, with a response rate of 48.8 %. Respondents reported a positive attitude: using evidence is necessary, the literature is useful, care is better when it is used. Then the behaviour figures: 17 % read fewer than two articles a month, and a quarter used the literature in their clinical decisions fewer than twice a month. The first barrier reported was lack of time⁹.

Why it is difficult: the documented barriers

If the obstacle were attitude, convincing people would be enough. The systematic review of barriers says it is not, and that changes the strategy completely.

Scurlock-Evans, Upton and Upton searched six databases on physiotherapy practice between 2000 and 2012, and retained 32 studies addressing either knowledge, attitudes or implementation of EBP, or interventions designed to improve it. Their conclusions come down to three findings⁵.

First finding: many physiotherapists hold positive attitudes towards EBP, but this does not necessarily translate into consistent, high-quality practice. Second finding: the barriers are numerous, foremost among them lack of time and lack of skills, along with mistaken beliefs about what EBP is. Third finding, and the most useful for acting on: there is no one-size-fits-all approach to improving implementation, and assessing the culture of the organisation before designing an intervention is decisive.

The internal critique: a movement in crisis?

This chapter exists because a practitioner who discovers EBP through its most enthusiastic advocates will eventually meet its limits, and will feel misled. Better to learn them from the people who set them out.

In June 2014, Greenhalgh, Howick and Maskrey published in the BMJ, on behalf of the Evidence Based Medicine Renaissance Group, an article whose title asks a question: is evidence-based medicine a movement in crisis? Their argument is that EBM has produced many benefits, and unintended negative consequences. They call for a refocus on usable evidence, combinable with context and professional expertise, so that each patient receives optimal treatment⁶.

A second critique, older and more radical, targets the raw material itself. Chalmers and Glasziou, in the Lancet in 2009, document the avoidable waste in the production and reporting of research: questions of no interest to clinicians or patients, inadequate study designs and methods, non-publication, and incomplete or unusable reports¹⁰. A practitioner who conscientiously reads the literature is therefore reading, in part, research that should not have existed in that form.

How do you ask a question that can be answered?

This is the step we skip, and it is the one that determines everything else. A badly framed question leads to hours of unusable reading.

Four elements, in order

The tried and tested format breaks the question into four elements: the population (who this patient is, precisely), the intervention under consideration, the relevant comparison (against what, including against no treatment or against waiting), and the outcome that matters to this patient.

Two elements deserve particular emphasis. The comparison, because it is almost always left out: “do shockwaves work?” has no answer, “do they do better than a progressive exercise programme in calcific tendinopathy of the shoulder?” does. And the outcome, because a study can be positive on an outcome the patient has no interest in.

Choose the source according to the question

This table is the most direct way round the mistaken belief that the barriers review identifies: searching for a randomised trial to answer a prognosis question means finding nothing, and then concluding that there is no evidence.

How do you read fast, and well?

Time is the first barrier reported. The answer is not to read more, it is to read in an order that lets you stop early.

What you look at before the result

1. The study's question : is it mine? Population, intervention, comparison, outcome. If the comparison is not the one that interests me, the study does not answer it.
2. The comparator, again: “against usual care” and “against nothing” are not read the same way, and that is exactly what separates a negative trial from a pointless one.
3. The primary outcome, and it alone. Secondary outcomes serve to generate hypotheses; a trial that is negative on its primary outcome remains a negative trial, however many favourable secondary outcomes it has.
4. The effect size and its confidence interval, not the p value. An interval that crosses the line of no effect says the effect cannot be distinguished from zero.
5. Clinical relevance : does the observed difference exceed the smallest change the patient can perceive?

The appraisal tools, and how reliable they really are

The PEDro scale rates the methodological quality of trials in rehabilitation, and its reliability has been measured. Two studies: eleven independent raters on 25 trials, then two raters on 120 trials with a third adjudicating. Item-level kappas run from 0.36 - 0.80 for individual raters and from 0.50 to 0.79 for consensus ratings. For the total score, the intraclass correlation coefficient is 0.56 (95 % CI 0.47 to 0.65) for a single rater, and 0.68 (0.57 to 0.76) by consensus. The authors describe this reliability as “fair” to “good”¹¹.

The practical lesson is not to give up the scale, it is not to over-read a one-point gap: a trial rated 6 out of 10 and a trial rated 7 out of 10 cannot be reliably told apart.

One level up, the GRADE approach rates the quality of the body of evidence for a given outcome, and the strength of the recommendation that follows from it, in only two categories for the latter. This is what most of the systematic reviews and guidelines cited on this site use⁷. A practitioner does not have to do the rating: they have to be able to read “moderate certainty” or “very low quality” when they meet them, and to draw the consequences in what they tell the patient.

How do you decide with the patient, rather than for them?

This is the pillar most often missing from EBP training, and yet it is the one without which the other two produce nothing. It rests on a measured finding: expectations are wrong, on both sides.

What patients expect

Hoffmann and Del Mar screened 15,343 references and retained 36 articles from 35 studies, totalling 27,323 patients, whose expectations of benefit or harm had been quantified. Result: among the 34 outcomes for which data on overestimation were available, the majority of participants overestimated the benefit for 22 of them (65 %). For harms, across 15 usable outcomes, the majority underestimated the harm for 10 (67 %). A correct estimate by at least half of the participants occurred for only two benefit outcomes and two harm outcomes³.

What clinicians expect

Two years later, the same authors applied the same method to professionals: 8,166 references screened, 48 articles, 13,011 clinicians. Among the studies comparing benefit expectations with a correct answer (28 outcomes in all), the majority of participants gave a correct estimate for 3 outcomes only (11 %). For harms (69 outcomes), a majority estimated correctly in 9 cases (13 %). The direction of the error is consistent: clinicians underestimate harms more often and overestimate benefits more often⁴.

Why the two are inseparable

Hoffmann, Montori and Del Mar wrote it in 2014 in JAMA : shared decision making and evidence-based medicine are connected, and each is incomplete without the other. Without shared decision making, EBP degenerates into mechanical application; without evidence, shared decision making is not informed⁸.

How do you clear out your practice?

Adding recommended treatments is half the job. The other half is removing the ones that are not recommended, and it is the harder half, because it touches habits that look as though they work.

The Choosing Wisely movement was designed for this: reducing low-value care by encouraging professionals and patients to discuss unnecessary tests and treatments. Its uptake in physiotherapy was mapped in 2025: out of 127 national associations affiliated to World Physiotherapy, only seven (5.5 %) carried Choosing Wisely recommendations, those of Brazil, the United States, Norway, Italy, Australia, Spain and Switzerland. Between them, those seven associations carried 62 recommendations, of which 48.4 % in musculoskeletal practice, 27.4 % on mixed topics, 14.5 % in women's health, 6.4 % in cardiorespiratory practice and 3.2 % in neurology¹².

That figure of 5.5 % says something about the profession: the collective clearing-out effort is marginal, and it therefore rests, for the most part, on individual decisions.

Three questions for sorting

• What does this practice rest on? If the answer is “we have always done it this way” or “it works well for me”, that is exactly the territory where clinical estimation is poorly calibrated.
• What is its opportunity cost? Twenty minutes of passive treatment in a thirty-minute session are twenty minutes not given to something with a documented effect.
• What does it tell the patient? A repeated passive modality implicitly teaches that recovery comes from outside. That is a message, and it has consequences for adherence to exercise.

A weekly routine you can actually keep?

Since the barrier is time, any proposal that demands a lot of it will fail. What follows fits into an hour a week, and is not a validated recommendation: it is an arrangement derived from the documented barriers.

One question a week makes about forty questions a year. That is well below what an ideal of exhaustive reading would imply, and well above what the behaviour surveys describe. That is where the calibration sits.

Frequently asked questions

Do you need a paid subscription to practise EBP?

Not for most rehabilitation questions. Clinical practice guidelines, Cochrane reviews in many countries, PubMed Central and the PEDro database cover a large part of the field. Access to publications nevertheless remains a documented barrier, and stopping at the abstract is a risky compromise: an abstract presents results in their best light.

What do you do when there is no evidence at all?

That is the most frequent case, and the concordance review shows it: the “no recommendation” category dominates by a wide margin. You then fall back on the other two components, clinical expertise and patient values, and you say so explicitly to the patient. “There is no study on this point, here is what I am proposing and why” is an EBP sentence, not an admission of weakness.

So does my experience count for nothing?

It counts for a third of the definition, and it is irreplaceable for recognising a presentation, adapting an exercise, sensing reluctance. What the data show is that it is poorly calibrated for estimating effect sizes : for only 11 % of outcomes did a majority of clinicians estimate a benefit correctly. The two statements coexist without contradicting each other.

What do you say to a patient who has read something else online?

Take what they bring seriously, then put the figures on the table. The review of patient expectations shows that they massively overestimate benefits: the disagreement is most often about an order of magnitude, not about a principle. Give a figure, state its uncertainty, and decide together.

How do you know whether a guideline is reliable?

Look at whether it states the quality of the evidence and the strength of the recommendation separately, which is what the GRADE approach does. A guideline that asserts without rating its level of evidence needs checking at source.

Should you stop everything that is not proven?

No, and that would be a misreading. “Non-recommended” and “no recommendation” are not the same thing: the first category calls for withdrawal, the second calls for clinical judgement and transparency. It is the 43 % of non-recommended treatments that deserve attention, not the 81 % with no recommendation.

Is EBP compatible with private practice?

The time constraint is real and documented as the first barrier. That is precisely why the routine proposed here fits into an hour a week and one question at a time. The barriers review also stresses that there is no one-size-fits-all approach and that the culture of the workplace matters: in a group practice, the question of the week can be shared.

References

Twelve references, resolved one by one through the PubMed E-utilities API. For each of them the abstract was read in full and the figures cited in the article checked at source. The year kept is that of the issue, re-read on the XML record: the first “year” field of a PubMed record is sometimes a revision date, and shifts the citation by a year.

Three articles in the corpus take this one further on the regulatory side of professional practice: how the DPC works, the evaluation of professional practice and periodic certification, which make keeping knowledge up to date an obligation rather than a choice. For a concrete example of what this method gives when applied to a clinical topic, the article on tibialis anterior tendinopathy shows what can honestly be written about a subject on which no randomised trial exists.