Clinical Expertise in the Era of Evidence‐Based Medicine and Patient Choice (editorial)

Scenario You are caring for a 68 year old man with hypertension (intermittently con&olled) with a remote GI bleed and nonvalvular atrial fibrillation for 3 months and an enlarged left atrium (so cardioversion is unlikely), with no history Of strokes or TIAs. His father experienced a debilitating stroke several years ago and when he learns that his aha1 fibrillation places him at higher risk for a stroke, he is visibly distressed. Introduction The concepts of evidence-based medicine are in evolution as limitations of early models are addressed. In this article, we present a new model for evidence-based clinical decision making based on patients’ circumstances, patients’ preferences and actions, and best research evidence, With a central role for clinical expertise to integrate these components. Evidence-based clinical practice in evolution Traditionally, clinicians have been credited for clinical acumen according to their skills in making a diagnosis and prescribing or administering a treatment. The advent of major investments in biomedical research, leading to new and better tests and treatments, has spurred the development of critical appraisal of the medical literature and evidencebased medicine ( I ) , and application of current best evidence from health care research has become an expected adjunct to clinical acumen. Initially, the focus of evidence-based medicine was largely on determining the best research evidence relevant to a clinical problem or decision, and applying that evidence in resolving the issue. This early formulation de-emphasized traditional determinants of clinical decisions, including physiological rationale and individual clinical experience. Subsequent versions of evidence-based decision-making have emphasized that research evidence alone is not an adequate guide to action. Rather, clinicians must apply their expertise to assess the patient’s problem, and must also incorporate the research evidence and the patient’s preferences or values, before making a management recommendation (2) (Figure 1).