At its simplest level, we can use reflection to assess clinical outcomes – either as an individual or as a group (e.g. during clinical rounds). This is a simple and direct method of pulling out the essence of EBVM.

If you have made a decision, reflect on how you arrived at that decision. Ideally, reflection should be informed by referring to the literature, as well as just relying on the information you have to hand. It is then that you can really put the whole EBVM cycle to the test: ASKing the correct question, ACQUIREing and APPRAISEing the evidence, APPLYing that information and then finally ASSESSing if the application was appropriate. We often only reflect on the cases where something went wrong or we had an unexpected outcome, but any decision can benefit from reflection – be it a decision on diagnostic testing, treatment, or any other part of the management of a case.

During monthly clinical rounds in a busy small animal practice, Sam reported that his last case of cranial cruciate ligament (CCL) rupture had re-presented with rupture of the CCL in the contralateral limb three months after surgery.

On presentation, Sam had noticed that the dog was not using the limb he had initially operated on, and suspected poor return to function of the operated limb had been a factor. The owner was upset because when she had anterior cruciate ligament surgery herself, she had received an intensive programme of physiotherapy postoperatively, and wondered if the lack of physiotherapy could have been a factor in her dog’s new CCL injury.

One of Sam’s colleagues, Nicky, could recall similar cases in the practice and remembered reading a paper about early intensive physiotherapy used postoperatively after CCL surgery in dogs. Sam and Nicky worked together in an informal EBVM cycle of reflection, asking the question ‘In dogs with CCL injury, does postoperative physiotherapy compared to our traditionally prescribed controlled exercise programme improve function in the operated limb?’. They found a few papers that supported this approach, and although the evidence was not based on large multicentre trials in dogs, they felt there was sufficient evidence to apply physiotherapy as part of the postoperative management plan.

Canine hydrotherapyTogether they looked up their local physiotherapy animal special interest group, found a local animal-qualified physiotherapist and implemented referral for postoperative physiotherapy immediately, starting with Sam’s patient following its second surgery.

The head nurse was tasked with keeping a record of the cases of contralateral limb rupture as well as documenting client feedback on the physiotherapy, all of which were scheduled to be reviewed in a meeting in 12 months’ time.


  • This example shows a simple use of EBVM to address a problem following reflection on a case (it could equally have been used pro-actively before a problem arose).
  • A question was asked, information was acquired and appraised (albeit relatively informally), and the veterinarians applied the information in developing a new management protocol for dogs with CCL injury.
  • In order to ensure that this new management protocol is actually doing what the veterinarians hope it will do, it is essential that they also implement a system to assess the response against clear criteria. In this case the criteria are:
    1. The number of cases presenting for contralateral limb CCL injury.
    2. Client feedback on the management protocol.
  • A realistic time frame was set in order to ensure the protocol could be appropriately evaluated.

Reflection and unstructured EBVM is simple and easy to incorporate into everyday practice, but it is important to try to still follow the ‘ABCs’. Reflection without support of the literature or without a clear question can lead to a vague outcome.


It has been recognised in the medical field that most clinicians (including ‘experts’) only remember clearly their last three cases of a particular condition, and this impacts on how they manage the next case – reflection should always include sourcing appropriate information to support that reflection!