For the clinical expert to have a place in the hierarchy of evidence-based dentistry, the clinician expert’s knowledge and experience must be based on some kind of evidence.
Sharing knowledge is an important ingredient for bringing about change. New discoveries can inspire and transform common ways of thinking and lead to improved and better practice recommendations and outcomes.
Unfortunately, misrepresentation and misuse of investigational findings can have the opposite affect. They can stymie scientific advancement and halt clinical progress.
Reliable, high-quality information forms the foundation of our reality—our perception of facts and truth—but the interpretation of knowledge is the catalyst for change. How we assess the quality of information (and how we understand and use it) has become a major topic of discussion in the scientific literature, mostly under the rubric of evidence-based medicine or dentistry (EBD).
In the hierarchy of EBD, systematic reviews of randomized controlled trials and individual randomized controlled trials are recognized as the strongest levels of evidence. Expert opinion is the weakest.1 It has been suggested that applying and implementing clinical guidelines should turn to expert opinion only when research is lacking.2 As much as possible, therefore, evidence-based dental practice guidelines should be based on the interpretation of research findings and their subsequent transfer into the clinical setting. This greatly limits the influence of a particular person’s clinical experience on clinical practice guidelines.
To validate empirical observations of practical experience as "research findings," such observations must be documented through systematically designed experiments. The strength or weakness of the evidence depends on the consistency (similar findings with different study designs), the quantity (number of studies, study sample sizes, magnitude of effect) and the quality (minimized biases) of the studies.2 When the evidence is weak, more emphasis is placed on patients’ values and treatment cost.3 Patients’ values may carry less weight when the evidence is stronger.4
The process of EBD facilitates translation of evidence—usually based on large numbers of studies involving large groups of patients—into delivering and improving quality care, and the subsequent creation of clinical practice guidelines. Has the time come to replace the traditional authority, the expert clinician, with evidence-based practice guidelines? To answer that question, at least two important concerns need to be addressed:
- – Will these evidence-based guidelines apply equally to particular patients?
- – What should a practitioner do when the evidence is weak?
The clinical expert can provide the bridge between the science and the art of dentistry, and help fill the gap when the evidence is weak or lacking. However, this statement comes with a major caveat: For the clinical expert to help fill the gap, he or she must be familiar with the available evidence.
Having consistently achieved high-quality results with a large number of patients does not provide evidence that the results achieved can be reproduced in other settings by other providers. As Sackett and colleagues5 observed, however, "Without clinical experience, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient." Unquestionably, daily clinical decision making in dentistry still is based on personal empirical data.
Many studies assessing the evidence in dentistry have addressed an understanding of diseases rather than the patient benefit of a particular treatment—the "patient-oriented evidence that matters" (POEMs). Clearly, clinicians care very much about POEMs, about enhancing patients’ quality of life, about improving function and esthetics and about cost outcomes.
For the clinical expert to have a place in the hierarchy of EBD, the clinician expert’s knowledge and experience must be based on some kind of evidence. A perception of clinical excellence usually is not based on scientific evidence, but on subjectivity and our own values and expectations. In the era of EBD, the role of the expert clinician must be redefined. His or her opinions play a part in EBD (Who but the expert clinician can ask the most insightful questions?) but should not be construed as evidence.
Having consistently achieved high-quality results with a large number of patients does not provide evidence that the results achieved can be reproduced in other settings by other providers.
Problems arise when practitioners rely on these opinions before they have been challenged by scientific rigor. Probably one of the most important tasks for the expert clinician is to provide the context for clinical practice guidelines—a crucial step for the implementation of EBD in everyday practice.
In the American Heritage Dictionary,6 the word "empiric" has two meanings:
- – "one who is guided by practical experience rather than precepts or theory";
- – "an unqualified or dishonest practitioner; a charlatan."
As an editor I have, through practical experience, become somewhat of an expert in writing editorials. By definition, however, I would appear to be unqualified to do so, as I do not follow any specific principle or theory—only my own intuition. And that is the truth.
