Patient-centered, evidence-based decision making.

Butler • Editorial M physicians are committed to providing evidence-based care that is patient-centered and responsive to the clinical circumstances and values of each individual patient. However, there is increasing pressure from payers and those who attempt to define and measure quality in medical encounters for physicians to uniformly apply clinical guidelines to patients and minimize variance in clinical care.1-4 These 2 approaches are not always compatible and thus may create conflict for patients and physicians. In this issue of JAOA—The Journal of the American Osteopathic Association, Good and Rogers5 provide insight into theses complexities and use the clinical circumstance of atrial fibrillation to illustrate how primary and specialty care physicians might navigate these competing forces. The authors make a distinction between a “goal” of care (ie, “the focus and aspirations of a treatment”) and a “guideline” that sets a “standard, or expectation, of treatment.”5 The former captures the spirit of patient-centered care, while the latter attempts to provide an evidence-based platform, built from studies of groups of patients, that a single patient might stand on. These 2 concepts (ie, patient-centered care and evidence-based medicine) are distinct yet intertwined. Patient-centered care is an approach to the medical encounter that encourages patients to be active participants in their health and invites them to express their values and preferences for clinical care.6 Evidence-based medicine is a model of medical decision-making that incorporates 4 overlapping domains, 2 of which emphasize aspects of patient-centered care.7 Three of the evidence-based medicine domains—research evidence, patients’ preferences and actions, and clinical state and circumstance—can be illustrated using a Venn diagram (Figure). A fourth overriding circle illustrates the role of clinical expertise. In their article, Good and Rogers5 describe the role of each of these domains and point out how the weight of a given domain may change according to the nature and urgency of the clinical decision. There will be times when clinical expertise clearly dominates (eg, the choice of which heart rate–controlling medication, as well as the dose and route, to use in an acute situation) and times when patient preference and clinical state should dominate (eg, the long-term decision to engage in stroke risk reduction with warfarin or antiplatelet therapy). What is the role of research evidence in clinical decisions? When thinking about clinical decisionmaking, it is helpful to remember what research evidence can and cannot do for an individual physician caring for an individual patient. Research evidence cannot tell you if your patient will or will not benefit from a given intervention. The best that good research can do is describe the probabilities of various outcomes that might result when a given intervention or treatment is applied to an individual patient. As implied by Good and Rogers,5 no cardiologist can say with certainty that a given patient with refractory atrial fibrillation will benefit from ablation therapy. However, a physician applying a patientcentered, evidence-based approach should be able to describe the probabilities of the various outcomes resulting from the intervention, within the realm of statistical uncertainty, and then attempt to juxtapose this information alongside the patient’s desires and his or her wishes for medical care. How might one apply this methodology to a clinical scenario? In their article, Good and Rogers5 present an illustrative case of a 72-yearold man with atrial fibrillation and 2 additional stroke risk factors (diabetes and hypertension) who would like to stop taking warfarin. After a review of updated guidelines and individual research articles, the authors suggest that a combination of aspirin and clopidogrel may be his best available option. However, a more patient-centered, evidence-based approach would attempt to provide this patient with a better assessment of the risks and benefits of his treatment options, allowing him to generate more realistic expectations for the outcomes of therapy vs no therapy. To illustrate this point further, the patient’s CHADS2 (Congestive Heart Failure, Hypertension, Age ⩾75 Years, Diabetes, Stroke History [2 Points]) score of 2 suggests the probability of an adjusted annual stroke rate of 4% with no therapy.8 Using outcome data EDITORIAL