How medical training needs to change to allow true evidence-informed decision-making

Blog entry written on: Teaching clinicians shared decision making and risk communication online: an evaluation study (bmjebm-2020-111521)

Authors: Alexandra Freeman, Tammy C. Hoffmann, Chris Del Mar, Ramai Santhirapala

At the heart of evidence-based medicine is a pipeline: a flow of knowledge and insight from researchers’ computers to the patient’s clinic, where their clinician can explain their healthcare choices and likely outcomes.  Together, patient and clinician make a shared decision, based on the evidence of likely benefits and harms derived from population-level figures, and the patient’s own circumstances, values and preferences.

Intuitively, this is how contemporary healthcare should work – but it requires clinicians to have two core skills: to be able to appraise and understand research evidence, and to translate and communicate about that evidence (including ‘the numbers’) to the individual patient in front of them.

Many clinicians, however, have apparently not received extensive training in either of these skills.

We attempted to help clinicians and medical students increase their skills in shared decision-making and risk communication through creating free, online training courses. As we describe in our paper “Teaching clinicians Shared Decision Making and Risk Communication online: An evaluation study”, for around half of people taking the course it was the only training they had been given in either discipline and only 5% of participants had received more than a single lecture or workshop on either.

On the positive side, this course was able to improve confidence in, and knowledge about, shared decision making. On the worrying side, though, it highlighted problems with clinicians’ numeracy.

Half of participants were unable to answer correctly a question testing their numeracy, and participants who got this question wrong appeared to score lower right across the course.

Concepts such as lead-time bias (which means that diagnosing diseases earlier without improving treatments can make ‘5-year survival’ figures improve without helping a single patient live longer) proved difficult, even for experienced clinicians. Calculations of absolute and relative risks (even with multiple-choice answers) also challenged many.

Informed decision-making relies on understanding the likelihood and size of potential harms and benefits. Clinicians who do not easily understand the evidence themselves cannot communicate it clearly to patients to support them reaching a decision.

Shared decision making is gaining prominence in the curricula of many health disciplines but one of the barriers for clinicians has been the difficulties of accessing face-to-face workshops. Our online courses were designed to remove this barrier. To that end they have been successful: they are freely available, popular and have increased the awareness and introductory skills of those who completed it. However, for shared – or even informed – decision making to be successful in clinic, it’s clear that more radical change is necessary. The evidence pipeline from research computer to clinic has a serious blockage: clinicians’ abilities to deal with numerical evidence.

We are hardly the first to draw attention to this issue: risk communicator Gerd Gigerenzer has been shining a light on the problem for at least 15 years, along with many others. What seems extraordinary is that in that time there appears to be little improvement in clinicians’ skills in this area, yet the demand for such skills has heightened with the increasing volume of evidence available to guide clinical decisions.

We hope that our free courses can help inspire teaching and Continuous Professional Development around risk communication and shared decision making, but our evaluation work shows that numeracy must also be addressed.  We call on medical schools and professional bodies to address this in their curricula and further professional training.

Clinicians need to graduate with confidence and competence in dealing with quantitative evidence. Patients need to be able to rely on their clinicians’ abilities to understand and communicate that evidence so that together, they can make collaborative and well-informed decisions.

Alexandra Freeman

Winton Centre for Risk & Evidence Communication, University of Cambridge


Tammy C. Hoffmann

Bond University Centre for Research in Evidence-Based Practice


Chris Del Mar

Bond University Faculty of Health Sciences and Medicine


Santhirapala, Ramai

Department of Anaesthesia and Perioperative Medicine, Guy’s and St Thomas’ NHS Foundation Trust



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