Clinical expertise in the era of evidence-based medicine and patient choice.

Y ou are caring for a 68-year-old man who has hypertension (intermittently controlled) with a remote gastrointestinal bleed and nonvalvular atrial fibrillation (NVAF) for 3 months and an enlarged left atrium (so cardioversion is unlikely). The patient has no history of stroke or transient ischemic attack. His father experienced a debilitating stroke several years ago, and when he learns that his atrial fibrillation places him at higher risk for a stroke, he is visibly distressed. The concepts of evidence-based medicine are evolving as limitations of early models are addressed. In this editorial, 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. Traditionally, clinicians have been credited with 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 evidence-based medicine (1), and application of current best evidence from health care research is now an expected adjunct to clinical acumen. Initially, evidence-based medicine focused mainly on determining the best research evidence relevant to a clinical problem or decision and applying that evidence to resolve the issue. This early formulation de-emphasized traditional determinants of clinical decisions, including physiologic 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). Figure 1. Early model of the key elements for evidence-based clinical decisions. Figure 1 is based on the first text of evidence-based medicine (3) and was published in an editorial that appeared in ACP Journal Club and Evidence-Based Medicine in 1996 along with this definition: " Evidence-based medicine is the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients " (4). The editorial also included the admonition that the definition of evidence-based medicine is evolving and will continue to be refined. Indeed, the concepts of evidence-based medicine have evolved considerably, and this model needs to be enhanced, especially for what is …