"The art of medicine"
Statistical significance does not equal clinical significance. EBM requires an accurate assessment of the quality and applicability of the evidence, clinical expertise, and prioritization of the patient’s values and preferences.
Does the evidence apply to my patient?
- Were the study participants similar to my patient? (Inclusion/exclusion criteria, similar comorbidities and disease course, relevant genetic differences)
- Were all important outcomes considered? (e.g. rosiglitazone approved for diabetes but later found increased CV mortality)
- Was the magnitude of the effect worth the risk of harm?
- Were the outcomes or benefits present within an acceptable time period to my patient?
- Was follow-up sufficient to detect later outcomes or harms?
- Were the benefits worth the costs and potential risks?
Listen to your patient
So you can integrate the best evidence and your clinical expertise to share in decision making with the patient.
- What are your patient’s experiences thus far? Disease course? Therapies tried?
- What are your patient’s concerns? Pain? Side effects? Costs?
- What are your patient’s preferences?
- What are your patient’s values?
Use Shared decision making: a process in which patients are active participants in clarifying options, discussing goals and priorities, planning actions and making preference-sensitive decisions. The Rochester Participatory Decision-Making Scale is one example of a validated model for shared decision making. It follows a simple format of ASK-INFORM-ASK.
- Invite patient’s/family’s participation
- Explain clinical issue, nature of decision
- Present alternatives
- Discuss pros & cons of alternatives
- Relay inherent uncertainties
- Assess understanding
- Examine barriers to follow-through
- Ascertain patient/family’s preference
- Clarify agreement/plan
- Ask patient/family for additional questions*