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December 2006
Evidence-Based Tip
Applying the Evidence: The Patient-centered approach
Evidence Based Medicine (EBM) has its critics. Some even like to refer to it as a fascist movement, where evidence rules absolutely and physician experience is not valued. In a recent editorial in U.S. News & World Report, Bernadine Healy, a former head of NIH, even claims that EBM has "its own ideological and political agenda separate from its clinical purpose."
Such distortions fall far from the vision of EBM's proponents and practitioners. EBM is a patient-centered approach, not a device for making rules. The application of evidence is part of a process founded in critical thinking, and is equally dependent on the health care provider's clinical knowledge and experience. For the evidence to be applied, it must be compatible with a particular patient's clinical assessment, co-morbidities, values, and socio-economic status.
It is important to ask questions of the evidence such as:
- Were the study patients similar to my patient? If the age, sex, and ethnicity of the study participants were different from those of my patient, can I even apply the results of that study?
- Were the outcomes that the patient considers important the ones that were recorded by the study? For example, the study may have reported on mortality rates, when my patient is more concerned with quality of life.
- What are the potential harms and benefits? My patient may put different weights on these than I would, or than a previous patient might have.
Applying the evidence also involves proper communication and an understanding of a patient's cultural, spiritual, and ethical values, as well as family, educational and economic status. For instance, the average reading level in the state of South Carolina is 5th grade. Conversations about benefits and harm must be presented on a patient-appropriate level. A second example concerns the discussion of a choice to undergo a procedure with a statistically small chance for success. In such a situation, the health care provider must understand and treat with respect a patient's spiritual and cultural values. The physician is ethically bound to offer his or her best clinical judgment, but is equally bound to explain a patient's choices and involve the patient in decisions about his or her care.
As Dr. Ron Teufel, pediatric hospitalist, explained, "Patient-centered care means that our care is in agreement with what the patient wants. EBM is a tool that informs us both, the patient and the doctor as to what care could be effective. The final decision is always based on what the doctor feels is reasonable care and the patient feels is right for them."
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