The 4th Pillar of Evidence Based Practice

We all know there is a 4th Pillar in clinical practice… in addition to the 3 Pillars emphasized by Sackett et al in 1996. We manage this pillar every day and it strongly influences the decisions we make when treating and advising your patients.  What is it?  3rd Party Payer Demands.

The 4th Pillar can change the type of assistive device you recommend, it can change the treatment you offer (no more than X visits of manual therapy), it can change the type of population you serve, it changes how you interact (one-on-one vs. double-book model).

We don’t like to think that we are swayed by these constraints, but we are. This can manifest itself in many ways.  Perhaps insurance doesn’t like more than 8 visits in the pool, but research and your expertise suggest that 14 would be better for this patient.  Your manager says “we don’t want this to get bounced back” so you discharge them earlier than you, the patient and the research deem necessary… and so it goes.

We can argue over whether these constraints are good or bad, whether they protect the patient from fraud or abuse, whether they get in the way of good treatment, etc and on.  But we all do realize, that when we are in the room one-on-one with the patient,creating a therapeutic alliance, that the room is quite crowded.  There are many opinions to be had and many values to balance.

This is not news to you, I am sure.  But perhaps these constraints and demands were not viewed in the light of clinical decision making, which they certainly are.  For example: If you are looking for a functional outcome… then how will you treat a patient who is elderly, retired, has good neck ROM and strength, but has neck pain and headache that benefits from skilled physical therapy.  From my experience the 4th Pillar does not care too much about just pain, but wants ‘functional’ gains.  I certainly see how this patient enters a PT clinic… but I’m not sure how this patient gets approved for more visits.

Sackett et al. suggests equal weight to the 3 Pillars.  I think that, for all the flaws of the system, (EBM: A Movement in Crisis,and  EBP: A Crisis in Movement )  it works extremely well considering all the variables of human life, behavior and beliefs.  I suppose we need to take an honest look at how much this 4th Pillar contributes to clinical reasoning and critical thinking when addressing the patient.

Does it impact your practice choices? Do you see it as protective of patient rights, or hindrance to quality care?

This is not a black-and-white issue. I could be wrong, and am happy to be so, but I certainly don’t enjoy how crowded the clinical interaction can sometimes be…

–Matt D

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