DISCUSSION: PATIENT PREFERENCES AND DECISION MAKING

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The Connection Between Evidence-Based Medicine and Shared Decision Making

Tammy C. Hoffmann, PhD1,2 ; Victor M. Montori, MD, MSc3 ; Chris Del Mar, MD, FRACGP1

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JAMA

Published Online: October 1, 2014

2014;312;(13):1295-1296. doi:10.1001/jama.2014.10186

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 inferences with their expertise, clinicians attempt a decision that reflects their patient’s values and circumstances. 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 after discussing the options, the benefits and harms, and considering the patient’s values, preferences, and circumstances. It is the intersection of patient-centered communication skills and EBM, in the pinnacle of good patient care ( Figure ).

Figure. The Interdependence of Evidence-Based Medicine and Shared Decision Making and the Need for Both as Part of Optimal Care

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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 preferences into decisions, they sometimes erroneously guess them. However, it is through evidence-informed deliberations that patients construct informed preferences. For patients who have to implement the decision and live with the consequences, it may be more pertinent 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, discussions with patients about the natural history of the condition, the possible options, the benefits and harms of each, and a quantification of these must be informed by the best available research evidence. If SDM does not incorporate this body of evidence, the preferences that patients express may not be based on reliable estimates of the risks and benefits of the options, and the resulting decisions not truly informed.

Why Is There a Disconnect?

A contributor to the existing disconnect between EBM and SDM may be that leaders, researchers, and teachers of EBM, and those of SDM, originated from, and historically tended to practice, research, publish, and collaborate, in different clusters. Some forms of SDM have emerged from patient communication, with much of its research presented in conferences and journals in this field. A seminal paper in 1997 4 conceptualized SDM as a model of treatment decision making and as a patient-clinician communication skill. However, it did so without any connection to EBM—perhaps not surprisingly, because EBM was in its infancy. 2

Conversely, with its origins in clinical epidemiology, much of the focus of EBM has been on methods and resources to facilitate locating, appraising, and synthesizing evidence. There has been much less focus on discussing this evidence with patients and engaging with them in its use (sometimes even disparagingly referred to as “soft” skills). Most of the EBM attention has involved scandals (eg, unpublished data, results “spin,” conflicts of interest) and the high technology milestones (eg, systems to make EBM better and easier). Information about using evidence in decision-making with patients has been scant.

Disconnect between the 2 approaches is also evident in, and maintained by, the teaching provided to clinicians and students, again often reflecting the backgrounds of their teachers. Opportunities to attend EBM teaching abound with content largely focused on forming questions and finding and critically appraising evidence. 5 Learning how to apply and integrate the evidence is usually absent, or mentioned in passing without skill training.

Realizing the Connection Between EBM and SDM

A logical place to start is by incorporating SDM skill training into EBM training. This will help to address not only the aforementioned deficits in EBM training but also the lack of SDM training opportunities presently available. Additionally, it may facilitate the uptake of SDM and, more broadly, evidence translation. Recent calls for SDM to be routinely incorporated into medical education present an immediate opportunity to capitalize on closely aligning the approaches.

Another place to start to bring EBM and SDM together is the development and implementation of clinical practice guidelines. Whereas most guidelines fail to consider patients’ preferences in formulating their recommendations, 6 some advise clinicians to talk with patients about the options but provide no guidance about how to do this and communicate the evidence in a way patients will understand. Shared decision making may be strongly recommended in guidelines when the options are closely matched in their advantages and disadvantages, when uncertainty in the evidence impairs determination of a clearly superior approach, or when the balance of benefits and risks depends on patient action, such as adherence to medication, monitoring, and diet in patients using warfarin.

Conclusions

Links between EBM and SDM have until recently been largely absent or at best implied. However, encouraging signs of interaction are emerging. For example, there has been some integration of the teaching of both, 7 exploration about how guidelines can be adapted to facilitate SDM, 8 , 9 and research and resource tools that recognize both approaches. Examples of the latter include research agenda and priority setting occurring in partnership with patients and clinicians to help provide relevant evidence for decision making; and a new evidence criterion for the International Patient Decision Aids Standards requiring citation of systematically assembled and up-to-date bodies of evidence, with their trustworthiness appraised, 10 thus aligning the development of SDM tools with contemporary requirements for the formulation of evidence-based guidelines. Also, independent flagship conferences focused on the practice of evidence-based health care and on the science of shared decision making are now convening joint meetings.

Medicine cannot, and should not, be practiced without up-to-date evidence. Nor can medicine be practiced without knowing and respecting the informed preferences of patients. Clinicians, researchers, teachers, and patients need to be aware of and actively facilitate the interdependent relationship of these approaches. Evidence-based medicine needs SDM, and SDM needs EBM. Patients need both.

Article Information

Corresponding Author: Victor M. Montori, MD, MSc, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First St SW, Plummer 3-35, Rochester, MN 55905 ( [email protected] ).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Montori reported serving on the board of the International Society for Evidence-based Healthcare; serving as Chair of the Seventh International Shared Decision Making Conference in 2013; that he is a member of the Steering Committee of the International Patient Decision Aids Standards; and that he is a member of the GRADE Working Group. The KER Unit (Dr Montori’s research group) produces and tests evidence-based shared decision making tools that are freely available at http://shareddecisions.mayoclinic.org . Dr Hoffmann reported that she is supported by a National Health and Medical Research Council of Australia (NHMRC)/Primary Health Care Research Evaluation and Development Career Development Fellowship (1033038), with funding provided by the Australian Department of Health and Ageing. Drs Hoffmann and Del Mar reported that they are coeditors of a book on evidence-based practice, for which they receive royalties.

Additional Information: Additional information abut evidence-based medicine and shared decision making is available online in Evidence-Based Medicine: An Oral History at http://ebm.jamanetwork.com .

References

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Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681-692. PubMed Google Scholar Crossref

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Decision Aids. MAGIC website. http://www.magicproject.org/decision-aids/ . Accessed July 24, 2014.

van der Weijden T, Pieterse AH, Koelewijn-van Loon MS, et al. How can clinical practice guidelines be adapted to facilitate shared decision making? a qualitative key-informant study. BMJ Qual Saf. 2013;22(10):855-863. PubMed Google Scholar Crossref

10.

Montori VM, LeBlanc A, Buchholz A, Stilwell DL, Tsapas A. Basing information on comprehensive, critically appraised, and up-to-date syntheses of the scientific evidence: a quality dimension of the International Patient Decision Aid Standards. BMC Med Inform Decis Mak. 2013;13(suppl 2):S5. PubMed Google Scholar Crossref

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