Evidence-based medicine (EBM) is defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” It’s based on a mathematical calculation of predicting risk and harm by studying large samples of people.
That’s important – evidence and data are a critical aspect of modern, quality medicine.
In practice, however, we need to bridge the gap between objective research and the subjectiveart of daily medicine. To accomplish this, a physician must do the following:
- Know the scientific research
- Integrate the research with his/her own individual clinical expertise from treating numerous patients with the same condition
- Consider the patient’s values and expectations
A physician might say, for example, “Let’s discuss what we know works from the available research; let me tell you about my experiences in practice with other patients; and let’s talk about what is most important to you – what you may want or not want.”
I emphasize “most important to you” because this is the part most healthcare consumers don’t realize – their experiences and preferences must be factored into decision making.
This includes taking the objective clinical research data and combining it with the subjective variations in your physiology, how your body is reacting to a condition, and the quality of life you hope to achieve for yourself. Furthermore, all of these things are subject to input from your personal, political, philosophical, religious, ethical, economic, and aesthetic values.
Three differing client examples
As I attend physician appointments and manage hospitalizations with clients, I participate in conversations that bring together evidence-based medicine and the individual patient’s personal preferences:
- Mrs. T. was hospitalized recently with a gastrointestinal obstruction from recurrent cancer that she’d been successfully battling for many years. After diagnostic testing was performed, the conversation turned to options available to her that would include a disfiguring surgical procedure followed by a new form of chemotherapy.The prospect of surgery was daunting, and when the discussion included the research studies that outlined the success rate of the chemotherapy at 25%, Mrs. T. reflected on her life’s journey, on what she’d endured already, her religious values, her need and desire for independence, the disfigurement described, the impact on her family and made the decision not to embark on the surgery, but instead to return home under Hospice care.
- Mr. S. had a diagnosis of prostate cancer. During the description of the risks and benefits of options available to him (each with nearly identical effectiveness), he chose a non-surgical option because he feared a wound infection, as he’d experienced such a thing 20 years earlier.
- Mr. W., who was diagnosed with atrial fibrillation, was offered a new, brand-name drug that would provide anti-coagulation, thus decreasing his risk of stroke. One of the benefits described was that periodic blood work was not required, something that was necessary when taking a generic drug that had been used for many years. Mr. W., however, was skeptical of the research – this new drug had not been in wide use for very long. That, coupled with the excessive out-of-pocket cost to him based on his Medicare Part D Prescription drug coverage, led him to stick with the generic drug and have periodic blood work to monitor effectiveness.
Three examples, each of which combined evidence-based data with individual preferences.
Participating in decision making: How do I stay involved?
When you prepare your agenda for meeting with a physician, be ready for discussions that employ evidenced-based medicine. Expect a physician to do the following:
- Discuss the most recently available research on diagnosis and treatment of that condition
- Include information about his/her experience treating other patients with that condition, and who may have a similar profile to you
- Ask about what’s important to you, including what you value, your preferences, fears you may have and what you would define as a positive outcome of an intervention
In the event discussions don’t proceed this way with a physician, here are some suggestions for directing the conversation. You can say things like…
- Can you help me understand what the most recent research reveals about my condition?
- What are the benefits and risks of what you are proposing?
- Are there alternatives to what you are suggesting and what are the risks and benefits of those alternatives?
- I’m assuming you’ve treated other patients similar to me with this condition. Please tell me about your experiences with them.
- I’d like to discuss my preferences about what you are proposing, taking into consideration my quality of life, my fears, my family and cost. Can we talk about each of them separately?
- Here is what I would define as a positive outcome of this plan; is it achievable?
Of course, these types of discussions can be both scary and complicated. That’s why, as I discussed in my January 2014 newsletter, it’s often beneficial to involve a Care Partner in both your appointments and decisions that need to be made.
As the healthcare delivery model continues to shift, and evidence-based medicine becomes more and more the norm, each of us will necessarily be more responsible for sharing in the decision making regarding our health and treatment plans. Preparing for this is critical to success for you and for your provider.