Assignment: Pinnacle of Good Patient
Assignment: Pinnacle of Good Patient
Copyright 2014 American Medical Association. All rights reserved.
The Connection Between Evidence-Based Medicine and Shared Decision Making
Evidence-based medicine (EBM) and shared decision making (SDM) are both essential to quality health care, yet the interdependence between these 2 approaches is not generally appreciated. Evidence-based medicine should begin and end with the patient: after finding and appraising the evidence and integrating its infer- ences with their expertise, clinicians attempt a deci- sion that reflects their patient’s values and circum- stances. Incorporating patient values, preferences, and circumstances is probably the most difficult and poorly mapped step—yet it receives the least attention.1 This has led to a common criticism that EBM ignores patients’ values and preferences—explicitly not its intention.2
Shared decision making is the process of clinician and patient jointly participating in a health decision af- ter discussing the options, the benefits and harms, and considering the patient’s values, preferences, and cir- cumstances. It is the intersection of patient-centered communication skills and EBM, in the pinnacle of good patient care (Figure).
One Without the Other? These approaches, for the most part, have evolved in parallel, yet neither can achieve its aim without the other. Without SDM, authentic EBM cannot occur.3 It is a mechanism by which evidence can be explicitly brought into the consultation and discussed with the patient. Even if clinicians attempt to incorporate patient prefer- ences into decisions, they sometimes erroneously guess them. However, it is through evidence-informed
deliberations that patients construct informed prefer- ences. For patients who have to implement the deci- sion and live with the consequences, it may be more per- tinent to realize that it is through this process that patients incorporate the evidence and expertise of the clinician, along with their values and preferences, into their decision-making. Without SDM, EBM can turn into evidence tyranny. Without SDM, evidence may poorly translate into practice and improved outcomes.
Likewise, without attention to the principles of EBM, SDM becomes limited because a number of its steps are inextricably linked to the evidence. For example, discus- sions with patients about the natural history of the con- dition, the possible options, the benefits and harms of each, and a quantification of these must be informed by
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