October 31, 2014

Making a case for patient-centered care

By Victor M. Montori

During the period 2013-2014, authors in the KER UNIT have published JAMA viewpoints that have expressed our philosophy of clinical care and research.

In June 2013, Hassan Murad and I wrote a viewpoint paper called Synthesizing Evidence: shifting the focus from individual studies to the body of evidence. In this article, we pointed out five reasons why it was important to focus on the body of evidence rather than on individual studies. Among these, was the importance of avoiding misleading evidence that results from design features focused on enhancing the stand-alone value of the single paper. Our bottom line was to rescue the importance of generosity in the construction of systematic reviews and meta-analysis that offer evidence that can support people at the frontline trying to practice evidence-based care.

In December 2013, again with that Hassan Murad and Juan Pablo Brito, we published the viewpoint entitled The Optimal Practice of Evidence-based Medicine: incorporating patient preferences in practice guidelines. In this article, which was focused on the challenges of incorporating preferences guidelines, we pointed out the importance of taking into account patient view in the consideration of the full range of outcomes that patient experience and consider critical, and in deciding the relative importance of these outcomes. We also made the case that guideline panels should not make strong recommendations when the best course of action heavily depends in patients’ context, values, and preferences. This opened the door to connecting guidelines with decision aids that could support the construction of informed preferences in patients who face clinical dilemmas with their clinicians. Of interest we also pointed out that the clinicians should remember that taking care of patients is supposed to be difficult and that guidelines while simplifying this task cannot really do so when patient preferences and context matter and in that case they cannot replace “clinicians’ compassionate and mindful engagement of the patient in making decisions together”. We pointed out that this, patient-centered care, is indeed the optimal practice of evidence-based medicine.

A couple of months later, again with Dr. Brito and Dr. Ting, we published a viewpoint applying these principles to the new cholesterol guidelines. In this instance, we were able to offer a video of the process of using the Statin Choice decision aid in patients that the guideline considered for the use of statins. We point out in this paper that the principal value of the new cholesterol guidelines was their ability to realize the opportunity to advance patient centered care and shared decision-making, enabling new conversations between clinicians and patients. We also invited policymakers to consider that the new performance measure target should be the proportion of eligible patients who were able to take part in shared decision-making.

Finally in October 2014, in collaboration with my colleagues Tammy Hoffman and Chris del Mar, we published a viewpoint making the connection between evidence-based medicine and shared decision-making, presenting shared decision-making as a manifestation of evidence-based medicine that uses patient centered communication to engage patients (figure). Perhaps the most important message of this paper was a statement that medicine cannot and should not be practice without up-to-date evidence and without knowing and respecting the informed preferences of patients. It called for clinicians, researchers, teachers, and patients to be aware of and actively facilitate the interdependent relationship of these approaches. The piece concluded with the notion that evidence-based medicine needs shared decision-making and that shared decision-making needs evidence based medicine. It finished by stating that patients need both. The two indeed will come together to some extent at the International Society for Evidence-based Healthcare meeting in Taipei and more fully in the joint meeting of this society and the International Shared Decision Making conference in July in Sydney.

This has been a wonderful year for a journey in which we have been able to make statements connecting the tools of evidence-based medicine (guidelines) with tools for shared decision making (decision aids) with our principles of patient centered care, integrity, and generosity that underpin the work of the KER UNIT.

 Victor Montori

Tags: Chris del Mar, decision aids, evidence based medicine, Hassan Murad, Henry Ting, International Shared Decision Making Conference, International Society for Evidence-based Healthcare, Jaun Pablo Brito, KER Unit, minimally disruptive medicine, Montori, Papers & Publications, patient-centered care, shared decision making, Shared decision making, Tamy Hoffman, viewpoint

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