1	Step 4: Integrate Findings with Clinical Expertise and Patient Needs
2	Table of Contents Unique Patients with Individual Medical Needs Are results applicable to my patient? The Art of Medicine Integrating Patient Preferences Exercise Tools & Links
3	Each patient is a unique individual with different medical needs. Individual patient factors to consider include not only sex, age, co-morbid conditions, and religious beliefs but also issues such as access to care and insurance status that may affect the use of “best evidence”.
4	Are results applicable to my patient? Are study participants of similar demographics, severity, and co-morbidity? Are treatment options feasible in our setting?
5	Video - Part 1 View movie as: QuickTime (.mov) Flash (.swf) Double-click on video for full-screen mode.
6	Are results applicable to my patient?: Outcomes What are potential benefits and harms to patient with and without therapy? What are our patients’ values/expectations for the treatment and outcome of the treatment?
7	Video - Part 2 View movie as: QuickTime (.mov) Flash (.swf) Double-click on video for full-screen mode.
8	Most Important Question Does my patient want this?
9	Video - Part 3 View movie as: QuickTime (.mov) Flash (.swf) Double-click on video for full-screen mode.
10	Medicine: An Art Form The “right answer” to a medical situation based on the best evidence will change based on patient factors. Cannot be memorized Prevents practicing evidence-based medicine from being an example of cookbook medicine
11	Integrating Patient Preferences: Presenting Risks and Benefits Patients’ decision are influenced by wording. Adjust phrasing to your patient Numbers may confuse some, but help others
12	Integrating Patient Preferences: Risks vs. Benefits: Example “The bad news is that someone in your condition has a 0.1% chance of death associated with this treatment. Are you willing to take this risk?” vs. “The good news is that there’s a 99.9% survival rate. So this procedure is relatively safe. Should we procede with it?”
13	Integrating Patient Preferences: Need to Balance Benefits and Risks Patients are more willingly when focusing on positive outcomes; more reluctant when focusing on negative ones.
14	Integrating Patient Preferences: Patients’ Differences Patients vary in their inclinations and aversions to risk. Patients vary in their ability to evaluate the significance of the risks and benefits. Presentation of evidence for both the risks and benefits must be suited to the patient.
15	Try it out: Set up Clinical Situation The following exercise will focus on integrating your findings with the patient’s needs. 1) Choose a familiar clinical situation that may require one of several possible interventions.
16	Try it out: Set up Patient Circumstances 2) Individualize your patients’ circumstances in terms of medical history, personal desires, and practical considerations (demographics, treatment availability, etc.).
17	Try it out: Apply EBM Steps 1-3 Use EBM step 1 to construct well-formed clinical questions for each of your patients. Be sure to identify the target population that each patient falls into. Use EBM step 2 to find evidence for clinical decisions relative to each of your patients’ needs. Use EBM step 3 to appraise the evidence.
18	Try it out: EBM Step 4 Study Considerations Now list some questions to specifically identify the individual needs of each of your patients. How applicable is the evidence you have obtained to each of your patients? Are the participants in the studies you found of similar demographics, severity, and co-morbidity?
19	Try it out: EBM Step 4 Practical Considerations Are treatment options feasible in your setting? What are potential benefits and harms to each patient with and without therapy? What are your patients’ values/ expectations for the treatment and its outcome?
20	Try it out: EBM Step 4 Patient Desires Now what questions should you ask each patient to further assess what each patient wants given the feasible alternatives? Write out a few ways that you would present the possible clinical interventions to each patient.
21	Try it out: EBM Step 4 in Review Did you identify both the benefits and risks of each? Did you word these possible interventions in a manner suitable to each patient? Did you provide sufficient evidence for your patients to make a well-informed decision, while reducing the tendency towards unnecessarily biasing their choice?
22	Links to Other Websites and Hands-On Activities User’s Guides to Evidence-based Practice From Centre for Health Evidence
23	Congratulations! You have successfully completed Step 4. The End