Shared decision making: science and action.

Dr Jones is a 55-year-old surgeon with class I angina. Her exercise stress echocardiogram shows mild ischemia involving 2 segments of the inferior wall, and diagnostic coronary angiography demonstrates a right coronary artery discrete, mid-80% stenosis. She is meeting with her cardiologist to decide whether to pursue percutaneous coronary intervention (PCI) with a drug-eluting stent or continue her current medications (aspirin, atorvastatin, metoprolol, and nitrates). Current research evidence suggests that PCI and medical therapy have comparable outcomes for death and myocardial infarction, as well as similar relief of angina symptoms at 1-year follow-up. 1 PCI might achieve more rapid relief of symptoms but with some risk for bleeding, stent thrombosis, and restenosis. This risk is not present with medications; however, these might take longer to titrate and achieve improvement of symptoms and have their own potential side effects. 4 have described the primary challenge facing American health care in the 21st century as the need to improve evidence-based, cost-effective, and patient-centered care. Although healthcare organizations and clinicians study, measure, and improve gaps in evidence-based and cost-effective care, patient-centered care lacks comparable science and action. Spatz and Spertus 4 have proposed shared decision making (SDM) as the path forward to achieve patient-centered care and have introduced a series of articles in Circulation: Cardiovascular Quality and Outcomes to describe the state of the science in SDM, design and test tools for SDM, implement SDM in clinical practice, understand measurement and outcomes of SDM, and promote policy and accountability in SDM. In this introductory article, we address the following questions: 1. Why do we need SDM? 2. How should we do SDM? 3. How should we measure SDM? 4. How should we promote SDM? 5. What are the future directions of SDM? Evidence-based medicine requires an explicit process in which clinicians determine the available options and the likelihood these will lead to favorable and unfavorable outcomes. This process involves 2 judgments. The first judgment concerns our confidence in the estimates of treatment effect across the outcomes that matter most to patients. 5 This confidence is high when those estimates are produced by unbiased, precise, consistent, fully reported, and directly applicable randomized trials. The second judgment is to determine which treatment best fits the patient's context, goals, values, and preferences. 6 Both judgments require clinical expertise and experience, but the second mandates patient expertise and experience. Thus, the full realization of evidence-based medicine necessitates …