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Epstein RM, Alper BS, Quill TE. Communicating Evidence for Participatory Decision Making. JAMA. 2004;291(19):2359–2366. doi:10.1001/jama.291.19.2359
Context Informed patients are more likely to actively participate in their care,
make wiser decisions, come to a common understanding with their physicians,
and adhere more fully to treatment; however, currently there are no evidence-based
guidelines for discussing clinical evidence with patients in the process of
making medical decisions.
Objective To identify ways to communicate evidence that improve patient understanding,
involvement in decisions, and outcomes.
Data Sources and Study Selection Systematic review of MEDLINE for the period 1966-2003 and review of
reference lists of retrieved articles to identify original research dealing
with communication between clinicians and patients and directly addressing
methods of presenting clinical evidence to patients.
Data Extraction Two investigators and a research assistant screened 367 abstracts and
2 investigators reviewed 51 full-text articles, yielding 8 potentially relevant
Data Synthesis Methods for communicating clinical evidence to patients include nonquantitative
general terms, numerical translation of clinical evidence, graphical representations,
and decision aids. Focus-group data suggest presenting options and/or equipoise
before asking patients about preferred decision-making roles or formats for
presenting details. Relative risk reductions may be misleading; absolute risk
is preferred. Order of information presented and time-frame of outcomes can
bias patient understanding. Limited evidence supports use of human stick figure
graphics or faces for single probabilities and vertical bar graphs for comparative
information. Less-educated and older patients preferred proportions to percentages
and did not appreciate confidence intervals. Studies of decision aids rarely
addressed patient-physician communication directly. No studies addressed clinical
outcomes of discussions of clinical evidence.
Conclusions There is a paucity of evidence to guide how physicians can most effectively
share clinical evidence with patients facing decisions; however, basing our
recommendations largely on related studies and expert opinion, we describe
means of accomplishing 5 communication tasks to address in framing and communicating
clinical evidence: understanding the patient's (and family members') experience
and expectations; building partnership; providing evidence, including a balanced
discussion of uncertainties; presenting recommendations informed by clinical
judgment and patient preferences; and checking for understanding and agreement.
Physicians should create collaborative partnerships with patients (and
families) in which clinical decisions are made using the best available evidence,
consistent with patients' values, goals, and capabilities.1 However,
this ideal is rarely achieved. Physicians typically spend less than 1 minute
out of a 20-minute visit discussing treatment and planning.2 Informed
decision making occurs in only 9% of outpatient office visits, and physicians
ask patients if they have questions in less than half.3,4 Although
patients generally want more information about their illnesses,5 they
recall only a fraction of the information physicians transmit.2,6
Communicating evidence to patients has practical, relational, and ethical
goals. Informed patients are more likely to participate actively in their
care, make wiser decisions, come to a common understanding with their physicians,
and adhere more fully to treatment. Communicating evidence can transform a
physician-dominated relationship into one that is relationship-centered.7 Patients have a right to understand their illness,
prognosis, and treatment options, regardless of whether they choose to participate
Patients care about how evidence is presented. Elwyn et al9 published
2 studies in which focus groups of physician-educators and residents defined
skills for shared decision making, including communicating evidence. These
skills were used rarely. Participants suggested that the decision options
be presented before eliciting the patient's preferred role in the decision
or determining the preferred formats for further discussion. The focus groups
in the study by Ford et al10 included a variety
of practitioners and patients and proposed evidence-based consultation skills
for discussing evidence and treatment choices with patients (Box 1). Although participants emphasized the importance
of conveying probabilities and risks to patients and suggested the use of
diagrams, they did not propose specific methods.
Ability to communicate complex information using nontechnical language Tailoring
the amount and pace of in formation to the patient's needs and preferences Drawing
diagrams to aid compre hension Considering the values of the pa tient
while weighing choices Explanation of the probability and risk for
each option Facilitative skills to encourage pa tient involvement Evaluation
of Internet information that patients might bring with them Creating
an environment in which patients feel comfortable asking questions Giving
patients time to take in the in formation Declaration of equipoise
when present Checking patient understanding Negotiation
*Adapted with permission.10
Using published evidence to guide clinical decisions has its perils.11 It is difficult to reconcile evidence based on populations
with care directed toward individuals having unique needs, concerns, and expectations.
Quantitative estimates of probability of given outcomes can be difficult to
establish prospectively. The values ascribed to relevant outcomes are often
subjective8 and depend on factors that may
be intangible but personally significant (eg, a death with dignity), context-dependent
factors (eg, risk of pregnancy), and the perspective of the decision maker
(eg, physician, patient, or social institution such as Medicare).12 Presenting evidence to patients on intermediate outcomes
such as "response rate" rather than morbidity and mortality may lead patients
to believe that they will feel better or live longer when, in fact, the intermediate
outcome measure (eg, shrinkage of the tumor demonstrated by computed tomography
scan) may only be one marker of disease activity and meaningless in terms
of mortality or functional status. The "utility" of each given outcome is
notoriously value laden.13 Utilities are not
universal but rather emerge through dialogue.14 Formal
decision analysis may use patients' values to guide recommendations but is
not a method for informing patients about evidence.15
While the skills in recognizing clinical questions that might drive
a search of the medical literature10 (sometimes
by eliciting the patient's view of the problem16,17)
and forming a researchable question have been described,18 the
communication skills required to conduct the important dialogues with patients
have not, and are not routinely covered during training in evidence-based
medicine. In this article, we explore how physicians can translate findings
from a literature search to the clinical encounter in a way that enhances
patient understanding and participation in their care. We frame those communication
skills within the context of participatory decision making; they also apply
to other situations, such as informing patients about prognosis. In order
to generate recommendations, we conducted a systematic search of the published
Using MEDLINE to search articles from the period 1966 to 2003, we conducted
a systematic review of articles that (1) reported original research, (2) dealt
with communication between clinicians and patients, and (3) directly addressed
methods of presenting clinical evidence to patients (details of the search
strategy are available from the authors on request). Two investigators and
a research assistant screened 367 abstracts and 2 investigators reviewed 51
full-text articles, yielding 2 articles that clearly met criteria19,20; 5 others9,10,21-23 were
considered "marginal." Reference lists of these and other articles, and searches
of authors' names, yielded no additional references. One recent, not-yet indexed
additional reference was sent to us by an astute librarian.24 The
focus-group studies9,10,21 that
proposed skills for communicating evidence were discussed above.
Chao et al24 used hypothetical scenarios
presented to preclinical medical students to examine 4 methods of presenting
survival benefits on chemotherapy decisions. Students' responses confirmed
prior studies25-27 that
suggested that presenting information using relative risk reduction (eg, "This
treatment will improve your chances of recovery by 50%") may be misleading
by exaggerating the significance of a positive effect, especially if the absolute
benefits are small or if the effects of the intervention are realized in the
distant future. Absolute survival benefits or numbers needed to treat were
difficult for patients to interpret; combinations of methods led to confusion.
In contrast, students were able to interpret absolute risk reductions clearly
and without confusion. However, the study cannot be generalized to patients
having less medical sophistication.
Mazur and Merz20 presented volunteers
with a series of survival curves comparing 2 hypothetical treatments and noted
that the order of presentation of the graphs influenced subsequent decision
making, especially in less-educated and older patients.
Schapira et al19 conducted focus groups
composed of women aged 40 to 65 years to compare different types of graphic
displays for presenting evidence. They suggested graphics using human stick
figures or faces for single probabilities and vertical bar graphs for comparative
information between 2 options. Stick figures or faces were judged easier to
identify with, more understandable, and less "clinical" than graphs. However,
patients sometimes interpreted the stick figures as representing higher risk;
this was true especially among less-educated patients. Schapira et al also
suggested using lower denominators (eg, 1 stick figure out of 10 rather than
10 out of 100) for stick-figure graphics. Graphs with vertical bars were preferred
to those with horizontal bars. Shapira et al did not study pie charts.
Describing proportions (eg, "One in 10 women will get breast cancer")
was considered more "people-oriented" than was describing probability (eg,
"You have a 10% chance of getting breast cancer"), which was considered more
mathematical and more difficult to understand by less-educated patients. However,
proportions were more likely to lead patients to attribute risk to others;
they assumed that they belonged to the healthy group.
Less-educated women felt that confidence intervals were "wishy-washy,"
whereas better-educated women preferred the expression of uncertainty. Women
younger than 50 years preferred 10-year risk time frames, whereas women aged
50 years or older preferred estimates of lifetime risk. The generalizability
of these findings is unclear. Also, graphs may require in-person explanations
to help patients interpret them correctly.
Decision aids are interactive products that use computer or workbook
formats to present information, options, and guidance through a decision process.
Some present evidence, but most simply elicit values without explicit discussion
of research findings. None of 87 studies of decision aids in a 2001 Cochrane
review28 directly addressed patient-physician
communication, although they did report presumed results of improved communication,
such as improved patient knowledge, satisfaction, and patient involvement
in decision making.23,28-30 The
impact of the decision aid on actual decisions or clinical outcomes is mixed,28,31 and it remains unclear whether the
effect is due to empowerment, provision of information, or enhanced patient-physician
communication triggered by the use of a decision aid.30 We
found only 2 studies, both investigating the same decision tool, which addressed—albeit
indirectly—communication between physicians and patients.22,23 These
studies suggested that more time may be required for postintervention visits23 and that decision aids can facilitate discussions
with family members.22
Other than the choice of graphic formats, the literature review gave
few detailed suggestions about how physicians can effectively incorporate
clinical evidence into routine medical encounters and no empirical support
for those suggestions. None of the articles addressed whether the method of
presenting clinical evidence to patients or discussing it with them affects
clinical outcomes. The following sections build on our review by considering
possible methods for communicating evidence to guide clinical decisions, drawing
on the general communication literature when available.
Consider a patient who has been successfully treated for major depression
with antidepressants and now, after 12 months of treatment, wonders if the
antidepressants should be continued or discontinued. A systematic review of
31 randomized trials comparing antidepressant continuation with discontinuation
concluded that continuing antidepressants reduced the risk of relapse within
the next 12 months.32 The average risk of relapse
across trials was 18% with active treatment and 41% with placebo (number needed
to treat, 4.3). Stated conversely, 59% of patients treated with placebo did
not experience relapse. These data come from aggregated studies; individual
risks of relapse depend on factors such as genetic predisposition and the
number, severity, and length of prior depressive episodes. The literature
and clinical experience suggest 4 ways of presenting these research findings:
description of benefits and harms in general conceptual terms, numerical translation
of clinical evidence, graphical representation of quantitative data, and decision-aid
Describing benefits and harms in general conceptual terms is considered
appropriate in settings in which scientific precision might obscure lay understanding.
Although we found no relevant research in medical settings, in experimental
settings verbal and numerical probabilities led to equal estimates of the
likelihood of a precise binary event (eg, winning/not winning a lottery).33 For a patient who is not numerically oriented, the
physician might say something like, "Continuing this medicine makes it less
likely that the depression will return, but many people can stop the medicine
and not have a recurrence." Further discussion depends on patients' understanding
of the evidence (eg, "Does this mean that the depression will come back if
I stop the medicine?") or values (eg, "I hate being on medication, so I would
really like to try stopping"). If the patient asks, "How much will it reduce
my chances of relapse?" the clinician can use a more quantitative approach.
However, there is tremendous variation in the interpretations of some, but
not all, expressions of probability.34 For
example, the word "rare" was interpreted as a 24% probability (SD, 30.5%)
by patients and 5% (SD, 6%) by physicians, whereas "frequent" was interpreted
similarly by physicians and patients.35 These
kinds of miscommunications are even more likely when physicians and patients
are not of the same race, ethnicity, or socioeconomic status.36-38
Numerical translation of clinical evidence generally provides a description
of the "average" patient. However, no patient is an average patient. Individualized
numerical translation of clinical evidence requires estimating each patient's
risk of relapse, comparing it with that estimated for the research study sample,
and extrapolating the clinical evidence to the individual patient. Although
few studies currently provide algorithms for such calculations, over time
this approach may become more precise. Such precision may not be needed, though.
For example, if a particular patient had a strong family history of depression
and had experienced a prior episode, the clinician might say, "Most patients
have a 40% chance of another episode of depression in the next 12 months if
they stop taking the medicine. But depression runs in your family and you've
had other episodes in the past, so I'd guess your chances of another episode
if we stop the medication are quite a bit higher. That means that you might
benefit more than most by continuing the medication." Conversely, if there
were no family history or prior episodes, the risk of relapse might be adjusted
downward. One such discussion is shown in Box 2.
Step 1: Understand the Patient's Experience and Expectations "What were you hoping for in this visit today?" "I just
want to make sure that I've touched on all of the important issues." "Would
you like to invite your [partner] in to discuss this together?" "Have
you known anyone with [your diagnosis]? What was their experience like?" [If
not, then "What have you heard, or what were you expecting?"] "You
have said that quality of life is more important than quantity, but in this
case does that still seem to make sense?"
Step 2: Build Partnerships "You might
feel uneasy, as this can be a difficult decision. I think I understand your
concerns and questions. Now I would like to help you understand the is sues
involved from my perspective so that we can make this decision together."
Step 3: Provide Evidence, Including Uncertainties "While there has been a lot of research about this question,
the answer still is not entirely clear. Let me explain my view of the dilemma." "While
we used to always treat ear infections with an antibiotic, research shows
that in cases with fewer than 2 days of pain, the antibiotic is usually not
neces sary and may cause more problems than it helps. Six out of 10 ear infections
resolve spontaneously within 24 hours." "Even though the evidence is
divided on this issue, I think that we can still make a reasonable decision."
Step 4: Present Recommendations "We
could try a tricyclic antidepressant that may help your pain, even though
the evidence is not in as to how well it works." "I think that you
should hold off antibiotics for now, but you can call me if you don't get
better and we can reconsider." "I'm going to suggest a medication that
could help strengthen your bones but that could also worsen your heartburn
if you are not careful. I think that [. . . . ] would be the best course of
Step 5: Check for Understanding and Agreement "Does
that make sense to you?" "Could you tell me how you understand the
treatment choices I've presented to you for your [disease]?"
"Do you see things differently?"
Word choice can introduce framing biases3;
a patient might make a different decision about a treatment if the physician
said, "There is a 90% chance that it won't help" rather than "There is a 10%
chance of benefit." Presenting statistics both ways is preferred.
Graphical representation of quantitative data may facilitate numerical
translation, particularly for commonly encountered clinical questions.39 Methods include pie charts,40 bar
graphs,40 line graphs,20 icons,41 and graphics using stick figures or faces.19 These often require explanation for patients to interpret
Decision-aid programs may be useful when comparing treatments that might
produce different outcomes and potential adverse effects that are valued differently
by separate patients. Decision aids may present a more balanced presentation
of options, improved patient participation in and satisfaction with the decision,
and some changes in patient preferences compared with oral presentation of
the information by the physician.42 Criteria
for selecting decision aids have been reviewed elsewhere.28
Generally, a "relationship-centered" approach43-48 not
only provides opportunities for information transfer but also enhances the
patient's ability to participate in care. Relationship-centered care differs
from paternalism (in which the physician has all of the relevant information
and sole decision-making responsibility) and from a radical "independent choice"
model48 (in which clinicians simply present
"the facts" without making a recommendation and place sole responsibility
for the decision on the patient).49 The consumer
movement, physicians' fears of lawsuits, and a genuine desire not to influence
patients all promote informed choice. But patients and families should not
be deprived of the clinician's prudent judgments50 grounded
in the knowledge of the patient, his or her family, the illness, and the relevant
medical literature. Clinicians should not merely tolerate input from the patients
but should implement relationship-centered care that includes active encouragement
and coaching to help patients be involved in medical dialogue and decisions.
Describing evidence to patients and their families depends on the characteristics
of the evidence (type of measure used, consistency of findings, magnitude
of effect), characteristics of the patient (cognitive capacity, desire for
information, attention to detail, mathematical and scientific understanding),
role of family members in the patient's care (primary decision maker, influential,
or uninvolved), and characteristics of the physician (orientation toward evidence,
Presenting evidence may be more straightforward in cases in which there
is high-quality evidence of improved outcomes and relatively low risk (eg,
use of angiotensin-converting enzyme inhibitors for patients with heart failure),
the patient is identified as the primary decision maker, the patient's values
are known, and his or her expectations are concordant with the physician's.5,51 In such cases, it may be expeditious
to inform the patient about the diagnosis and treatment, anticipate common
questions, and assist in implementation of the treatment plan without the
need for detailed discussions of evidence unless the patient requests it.
Even then, though, patient adherence might be enhanced by providing data and
Communicating evidence is most appropriate when the clinical issue is
deemed important by either the clinician or the patient, when the evidence
is ambiguous or the outcomes uncertain, and when the evidence is clear but
interpretations made by the patient and/or the family differ substantially
from the physician's.51,52 There
may be widely discrepant views about the importance of a clinical issue. For
example, using antibiotics to treat an otherwise healthy patient's upper respiratory
tract infection is ineffective and potentially harmful. However, a request
for antibiotics may be driven by unvoiced fears—for example, perhaps
a relative had had a life-threatening pneumonia that started with similar
symptoms. For that reason, a quick but routine inquiry about patients' fears,
ideas, and expectations in all visits should precede discussions of medical
No single approach will work with all patients, even in similar clinical
situations. For example, a study of women at risk of familial breast cancer
found no consensus regarding how they wanted their clinicians to explain their
personal risk.53 Some wanted numbers, whereas
others preferred words. Those wanting numbers varied among preferences for
percentages, proportions, or (rarely) odds. Thus, clinicians need a variety
of techniques to communicate evidence about diagnosis, treatment, risk, and
prognosis, as well as several ways of verifying that the information has been
Interpretations of medical evidence are always matters of subjectivity
and values. For example, a patient with asymptomatic human immunodeficiency
virus infection may understand the evidence that early initiation of antiretroviral
treatment can delay symptoms related to the infection. However, this fact
should be interpreted in the context of the patient's values; the patient
might decide that early treatment does not warrant the inconvenience, potential
adverse effects, and possible future viral resistance.
Family members of patients are often involved in health care decisions,
whether or not they are present during the clinical encounter. Patients from
some cultures tend to entrust the primary responsibility for medical information
and decisions to family members.54 But there
may be conflicts of values among family members; in one study of a decision-analysis
program for prostate cancer screening, men preferred a no-screening approach,
whereas their wives favored screening to a greater degree and also expressed
less concern about the impact of impotence and incontinence on quality of
life than did their husbands.55 Thus, the clinician
should simultaneously welcome family input and be vigilant about maintaining
the patient's primacy in the decision-making process. Patients' desire to
have family members involved in health care may not be explicit, so it is
useful to ask whenever there is a major decision about a potentially worrisome
Because of the paucity of evidence in our review, we also used related
literature and clinical experience to guide our recommendations. Evidence
from the general communication skills literature suggests that actively listening,
providing information in small "digestible" amounts, and pausing to check
for patient understanding will likely improve understanding and may shorten
visit times by eliminating transfer of information that the patient neither
needs nor wants.56-58 When
the patient is distressed, delaying discussions of evidence until the patient
is more receptive can reduce misunderstandings.59 Situations
such as initiation of antihypertensive medication are usually not urgent,
and the increased patient commitment gained by judicious delay may improve
concordance to a mutually agreed-upon plan. Time spent thinking and talking
with family members can help in the interpretation and presentation of complex
information and raise additional questions that are important to the patient.
Once options have been presented to the patient, detailed discussions
may follow; we propose a 5-step process that is informed by the needs and
perspectives of the patient as well as by the physician's expertise (Box 3). The model recognizes that
decision making is only partially a rational process; it also includes elements
of trust, confidence, and values.
Physician: It sounds like you've done well
on the antidepressant but don't know whether it's worth continuing. Is that
Physician: This is a difficult choice, and
the answer is not quite clear. Most people do well even if they don't take
an antidepressant medication. But, research shows that quite a few people
will have a relapse. And, if you take the medication, you're less likely to
have another episode of depression in the next 5 years.
Patient: Well, what would you do?
Physician: This is not an easy choice, so I
think that different people would make different decisions. But first, let
me make sure that you understand the issue.
Patient: Well, I think I understand, but how
certain is it that the depression will come back? The pills are okay, but
I really don't want to be on them for the rest of my life—they do affect
my sex life a bit.
Physician: Do you want statistics?
Patient: Okay—let's try.
Physician: There have been several research
studies, and it seems, overall, that of 10 patients with depression who stop
the medicine, 4 will have a recurrence within the next year, while 6 will
remain healthy. If they continued the medi cine, only 2 out of the 10 would
have a recurrence. Are you following me?
Patient: What's the choice then? I really don't
want to feel that way again!
Physician: You've hit the nail on the head.
You first said you did not want to take medication forever, and now you are
telling me that you clearly don't want to have a relapse. And that is the
choice we should make together.
Patient: I understand now. I guess the million-dollar
question is whether I'm go ing to be in the healthy group or the depressed
group. Is there any way to tell?
Physician: That's a good question—the
problem is, we really don't know. But we know that depression runs in your
family, so your risk for relapse might be some what higher than what is reported
in the research. So, a lot of physicians would suggest that you continue,
and I guess that I would agree, as long as the side effects are tolerable.
And, if not, there are other medications. And we can talk again in 6 to 12
months to see if it makes sense to continue.
Patient: Got it. I'll probably do it. I'm going
to need to think about this for a while.
Physician: Is there anything that we've discussed
that you don't understand?
Patient: Not really. I just need time to think.
Physician: Should we talk again next month?
Maybe continue the medication un til then?
Patient: Okay, sounds reasonable.
The scope and importance of the issue should be understood from the
patient's standpoint as well as the physician's. Even if the clinician has
inquired about the patient's perspective earlier in the visit, it is helpful
to delineate the patient's specific needs, fears, expectations, and context
specific to this issue. Also, this is the time to invite family members to
participate when appropriate.
Relationship-building activities include the expression of empathy (eg,
"You might feel uneasy"), acknowledgment of the complexity or difficulty of
the issue, an expression of mutual understanding (eg, "I think I understand.
. . . "), increasing patient/family involvement (eg, "I would like to help
you understand"), and fostering partnership (eg, "We need to make this decision
together"). This approach builds trust and facilitates transfer of important
Generally, patients want more information from their physicians than
they receive.60 Since some patients may not
know the appropriate questions or may be hesitant to ask, physicians should
anticipate critical unasked questions and suggest discussing them. Presenting
clinical uncertainty in simple lay terms can be challenging. Avoiding discussions
about uncertainty might preclude a patient's full understanding of a critical
decision. Overemphasizing uncertainty can also be problematic, as some patients
will lose confidence.34,61-65 Balance
is achieved by explaining the limitations of what is known while maintaining
confidence that this represents the imperfections of medical science rather
than lack of competence of the practitioner.61 It
is at this phase that the clinician should determine the appropriate format
for presenting evidence—for example, general descriptions, numbers,
educated guesses, graphics, or decision aids. Patients may have already found
information that they may or may not spontaneously discuss with the clinician.
Recommendations should only occur after the clinician has integrated
clinical evidence with the patient's values. Some decisions, especially when
the evidence is uncertain or mixed, may represent true equipoise—ie,
the physician may not have a specific recommendation—in which case the
physician should present options dispassionately. For other situations, in
which the evidence about benefits or harms is clearer, the physician may have
recommendations for how to best meet the patient's goals. If so, the physician
should inform the patient which course of action is recommended and explain
how that recommendation is generated clearly from the patient's goals and
the evidence. The physician then has the burden of differentiating evidence-based
recommendations from those generated from personal experience or bias (eg,
religious or financial concerns; desire for convenience).
Sometimes simply asking "Does that make sense to you?" may be adequate,
and a positive response can indicate that you can continue with your recommendations
and planning. In complex situations (such as the choice between cancer chemotherapy
regimens) it is helpful to ask the patient to summarize what he or she understands
and the rationale for the choice made. If the patient appears not to understand,
seems to agree but appears apprehensive, or actively disagrees, that is an
invitation to go back to exploring the patient's values, ideas, and expectations,
or to provide detailed information. Sometimes patients and families feel comfortable
enough to try out a treatment while reserving full agreement with the plan.
Additional resources may be useful for improving understanding and recall;
these include carefully selected Web sites, printed handouts, handwritten
instructions, review with nurses, audio recordings of the visit, and follow-up
Clinicians who have the flexibility to use different approaches can
more easily adapt to the different ways in which people learn or process information.
Finally, clinicians should be open to reconsidering medical decisions; many
medical decisions are at least partially reversible. By leaving the door open
for future discussions there is the possibility of responding to changing
We have proposed methods of helping patients and their families make
use of results of medical research to reach decisions that incorporate evidence
and patients' values. The ingredients for effective use of evidence include
understanding the patient's preferred style, informed flexibility in presenting
the information to accommodate to the patient's needs, a visit that is characterized
by dialogue rather than lecturing, and an active partnership in which the
patient is encouraged and coached to take a more active role in the consultation.
Paradoxically, although relationship-centered consultations in which there
is shared understanding and participatory decision making are associated with
better outcomes, there is little evidence to guide many of our other recommendations.
Further research will help define optimal ways of incorporating evidence into
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