Evidence Based Medicine

Step 4 - Incorporating the evidence with clinical judgment and patient preferences

This is the art of medicine. You present the benefits and risks of the procedure or treatment or test to a patient. With this information, the patient and you can make the best, most informed decision. This is the area that is also least well developed in evidence based medicine. There are no formulas to help you balance risks and benefits.

Research has shown that presenting probabilities to patients (as well as physicians) can be difficult. We also know that the way you frame your questions can influence a patient’s decision. "Mr. Jones, you have a 95% chance of surviving this operation" is different than "Mr. Jones, you have a 5% chance of dying this operation". Patients respond better to the half-full statement than the half-empty statement. And finally we also know that there are individuals who are risk takers and others who are more risk adverse. Physicians tend to view more of the benefits of a procedure. We need to remember to also present the risks.

There are a number of ways of eliciting patient preference, but none of them are very good. In general, in this area, it involves discussing with the patient and laying out the evidence for both the benefits and risks of the proposed intervention. This process may engage some patients. Others may tell you that it just sounds "too complicated – you do whatever you think is best, doc."

Again this is the art of medicine. Try to explain as clearly the risks and benefits. Present patients with the best evidence available. Attempt to engage the patient in this discussion. Each patient is different. Your job is to use your clinical judgment and experience to tailor the best evidence with the patient’s needs and wants.