Assignment: Conferences and Journals
deliberations that patients construct informed prefer- ences. For patients who have to implement the deci- sion and live with the consequences, it may be more per- tinent 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, discus- sions with patients about the natural history of the con- dition, 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 in- corporate this body of evidence, the preferences that pa- tients express may not be based on reliable estimates of the risks and benefits of the options, and the result- ing 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 teach- ers of EBM, and those of SDM, originated from, and his- torically tended to practice, research, publish, and col- laborate, 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 patient- clinician communication skill. However, it did so with- out any connection to EBM—perhaps not surprisingly, be- cause 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 synthe- sizing evidence. There has been much less focus on dis- cussing 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 Most of the EBM attention has involved scandals (eg, unpublished data, results “spin,” conflicts of interest) and the high technology mile- stones (eg, systems to make EBM better and easier). Information about using evidence in decision-making with patients has been scant.
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