Opinion
VIEWPOINT
Tammy C. Hoffmann, PhD Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia; and University of Queensland, Brisbane, Australia. Victor M. Montori, MD, MSc Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota. Chris Del Mar, MD, FRACGP Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.
Viewpoint page 1293
Corresponding Author: Victor M. Montori, MD, MSc, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First St SW, Plummer 3-35, Rochester, MN 55905 (montori.victor @mayo.edu).
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 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).
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 19974 conceptualized SDM as a model of treatment decision making and as a patientclinician 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 disOne Without the Other? These approaches, for the most part, have evolved in cussing this evidence with patients and engaging with parallel, yet neither can achieve its aim without the other. them in its use (sometimes even disparagingly referred Without SDM, authentic EBM cannot occur.3 It is a to as “soft” skills). Most of the EBM attention has mechanism by which evidence can be explicitly brought involved scandals (eg, unpublished data, results “spin,” into the consultation and discussed with the patient. conflicts of interest) and the high technology mileEven if clinicians attempt to incorporate patient prefer- stones (eg, systems to make EBM better and easier). ences into decisions, they sometimes erroneously Information about using evidence in decision-making guess them. However, it is through evidence-informed with patients has been scant. Disconnect between the 2 approaches is also evident in, and maintained by, the teaching provided to Without shared decision making, EBM clinicians and students, again often reflecting the backgrounds of their can turn into evidence tyranny. teachers. Opportunities to attend EBM teaching abound with content largely deliberations that patients construct informed prefer- focused on forming questions and finding and critiences. For patients who have to implement the deci- cally appraising evidence.5 Learning how to apply and sion and live with the consequences, it may be more per- integrate the evidence is usually absent, or mentioned tinent to realize that it is through this process that in passing without skill training. patients incorporate the evidence and expertise of the clinician, along with their values and preferences, into Realizing the Connection Between EBM and SDM their decision-making. Without SDM, EBM can turn into A logical place to start is by incorporating SDM skill trainevidence tyranny. Without SDM, evidence may poorly ing into EBM training. This will help to address not only translate into practice and improved outcomes. the aforementioned deficits in EBM training but also the Likewise, without attention to the principles of EBM, lack of SDM training opportunities presently available. SDM becomes limited because a number of its steps are Additionally, it may facilitate the uptake of SDM and, inextricably linked to the evidence. For example, discus- more broadly, evidence translation. Recent calls for SDM sions with patients about the natural history of the con- to be routinely incorporated into medical education predition, the possible options, the benefits and harms of sent an immediate opportunity to capitalize on closely each, and a quantification of these must be informed by aligning the approaches.
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Opinion Viewpoint
Figure. The Interdependence of Evidence-Based Medicine and Shared Decision Making and the Need for Both as Part of Optimal Care
Optimal patient care
Conclusions
Shared decision making
Evidence-based medicine
Patient-centered communication skills
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 ARTICLE INFORMATION 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.
1296
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.
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 upto-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-todate 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.
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 1. Straus SE, Jones G. What has evidence based medicine done for us? BMJ. 2004;329(7473):987988. 2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. 3. Greenhalgh T, Howick J, Maskrey N; Evidence Based Medicine Renaissance Group. Evidence based medicine: a movement in crisis? BMJ. 2014; 348:g3725. 4. 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. 5. Meats E, Heneghan C, Crilly M, Glasziou P. Evidence-based medicine teaching in UK medical schools. Med Teach. 2009;31(4):332-337.
6. Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA. 2013;310(23):2503-2504. 7. Hoffmann TC, Bennett S, Tomsett C, Del Mar C. Brief training of student clinicians in shared decision making: a single-blind randomized controlled trial. J Gen Intern Med. 2014;29(6):844-849. 8. Decision Aids. MAGIC website. http://www .magicproject.org/decision-aids/. Accessed July 24, 2014. 9. 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. 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.
JAMA October 1, 2014 Volume 312, Number 13
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 05/13/2015
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VIEWPOINT
Tammy C. Hoffmann, PhD Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia; and University of Queensland, Brisbane, Australia. Victor M. Montori, MD, MSc Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota. Chris Del Mar, MD, FRACGP Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.
Viewpoint page 1293
Corresponding Author: Victor M. Montori, MD, MSc, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First St SW, Plummer 3-35, Rochester, MN 55905 (montori.victor @mayo.edu).
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 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).
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 19974 conceptualized SDM as a model of treatment decision making and as a patientclinician 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 disOne Without the Other? These approaches, for the most part, have evolved in cussing this evidence with patients and engaging with parallel, yet neither can achieve its aim without the other. them in its use (sometimes even disparagingly referred Without SDM, authentic EBM cannot occur.3 It is a to as “soft” skills). Most of the EBM attention has mechanism by which evidence can be explicitly brought involved scandals (eg, unpublished data, results “spin,” into the consultation and discussed with the patient. conflicts of interest) and the high technology mileEven if clinicians attempt to incorporate patient prefer- stones (eg, systems to make EBM better and easier). ences into decisions, they sometimes erroneously Information about using evidence in decision-making guess them. However, it is through evidence-informed with patients has been scant. Disconnect between the 2 approaches is also evident in, and maintained by, the teaching provided to Without shared decision making, EBM clinicians and students, again often reflecting the backgrounds of their can turn into evidence tyranny. teachers. Opportunities to attend EBM teaching abound with content largely deliberations that patients construct informed prefer- focused on forming questions and finding and critiences. For patients who have to implement the deci- cally appraising evidence.5 Learning how to apply and sion and live with the consequences, it may be more per- integrate the evidence is usually absent, or mentioned tinent to realize that it is through this process that in passing without skill training. patients incorporate the evidence and expertise of the clinician, along with their values and preferences, into Realizing the Connection Between EBM and SDM their decision-making. Without SDM, EBM can turn into A logical place to start is by incorporating SDM skill trainevidence tyranny. Without SDM, evidence may poorly ing into EBM training. This will help to address not only translate into practice and improved outcomes. the aforementioned deficits in EBM training but also the Likewise, without attention to the principles of EBM, lack of SDM training opportunities presently available. SDM becomes limited because a number of its steps are Additionally, it may facilitate the uptake of SDM and, inextricably linked to the evidence. For example, discus- more broadly, evidence translation. Recent calls for SDM sions with patients about the natural history of the con- to be routinely incorporated into medical education predition, the possible options, the benefits and harms of sent an immediate opportunity to capitalize on closely each, and a quantification of these must be informed by aligning the approaches.
jama.com
JAMA October 1, 2014 Volume 312, Number 13
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 05/13/2015
1295
Opinion Viewpoint
Figure. The Interdependence of Evidence-Based Medicine and Shared Decision Making and the Need for Both as Part of Optimal Care
Optimal patient care
Conclusions
Shared decision making
Evidence-based medicine
Patient-centered communication skills
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 ARTICLE INFORMATION 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.
1296
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.
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 upto-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-todate 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.
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 1. Straus SE, Jones G. What has evidence based medicine done for us? BMJ. 2004;329(7473):987988. 2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. 3. Greenhalgh T, Howick J, Maskrey N; Evidence Based Medicine Renaissance Group. Evidence based medicine: a movement in crisis? BMJ. 2014; 348:g3725. 4. 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. 5. Meats E, Heneghan C, Crilly M, Glasziou P. Evidence-based medicine teaching in UK medical schools. Med Teach. 2009;31(4):332-337.
6. Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA. 2013;310(23):2503-2504. 7. Hoffmann TC, Bennett S, Tomsett C, Del Mar C. Brief training of student clinicians in shared decision making: a single-blind randomized controlled trial. J Gen Intern Med. 2014;29(6):844-849. 8. Decision Aids. MAGIC website. http://www .magicproject.org/decision-aids/. Accessed July 24, 2014. 9. 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. 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.
JAMA October 1, 2014 Volume 312, Number 13
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 05/13/2015
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