Review formulai and d as th efacofontctorfaming artid or charac tics of the healt re system). and (3 that raised the question of whether EBM isa"movement hidpaspe ence never nine deci not match what the best av The third p eping with a cutura istic and change n medic e over the past 20 making in eve erenc of shae Heal care face severe time love near c practice o en enefits and from its early days,EBM has focusedon the r repre championing randomised t in individ al patients pos of share de 10 of-1 ran nces in 6 T lution to ate and and smal eec ose with ba ine risk pdate roding guides for the crec ility of subgroup A third criticism is that EBM promote ased erise exper has indee oeec the share making Wher all qualified sionals in the fiel 0 dinicdliudgnme oper other determinan alth- ery by emphasis ing th de ous judgment in critical apprais tion fram clinical setting. Anothe rcriticism of EBM is that there is no high decisions aids represents a frontier for future EBM care.We would rebut by noting the history of a deca de-o advance nore imp ing in Criticism of EBM highlighting ample s.The nticisms that such as lidocaine to tients after m of the scientific met o have bee ing intants on t 1A),which wed a receded the wides read implementation of EBM ow and ost 15 years fo ave also daim ed that EE EBM rch ofeegitn by the lear ed how to exploit EBM pr have beer ramewor effectively ad the (figure 1B) and medicalising issues that are better ,16.2017http dx.doiorg10.1016/50140-673616315926 Review 6 www.thelancet.com Published online February 16, 2017 http://dx.doi.org/10.1016/S0140-6736(16)31592-6 Development of tools to improve decision making The many factors that determine peoples’ decision making can be classifi ed as the eff ect of (1) context or framing, (2) situational or contextual factors (eg, psychosocial context or characteristics of the health-care system), and (3) individual characteristics of a decision maker (eg, experience, cultural background, and values and preferences).80,81 The individual characteristics of a decision maker relates to the third principle of EBM: evidence never determines decisions; it is always evidence in the context of values and preferences. The third principle of EBM is in keeping with a cultural change in medicine over the past 20 years: the growing emphasis on patient autonomy, and the associated priority given to shared decision making. Although widely acknowledged as desirable, the challenges to the implementation of shared decision making remain formidable. Health-care providers face severe time constraints and might not have the relevant evidence readily available or the skills necessary to optimally engage patients. Decision aids that communicate harms, benefi ts, and alternatives in an easily understood manner represent a possible solution to the challenges of shared decision making.82 These too face challenges: they are often based on inadequate and inaccurate evidence summaries from the start; if optimally evidence-based at the start, they fail to update appropriately; and, designed essentially as patient information, they often achieve little in the way of facilitating useful discussion between clinicians and patients.83 Point-of-care decision aids specifi cally designed for the clinician—patient encounter show promise for advancing the shared decision making cause. When created from the previously mentioned electronic platforms, developers can access and present the best updated evidence for the clinician to share on electronic devices.45 Formal user testing has provided a format that allows the developer to address the two other determinants of decision making introduced at the beginning of this section: framing of the information and ensuring relevance to the particular clinical setting. Further development, testing, and dissemination of point-of-care decisions aids represents a frontier for future EBM advances. Criticism of EBM Persistent criticisms of EBM have focused on three major issues. The fi rst argues that EBM relies on reductionism of the scientifi c method;84,85 critics have been particularly vocal regarding overly strict adherence to the evidence hierarchy pyramid (fi gure 1A), which they viewed as narrow and simplistic.28,84–86 It took almost 15 years for EBM to respond fully to this legitimate concern; the sophisticated hierarchy of evidence off ered by the GRADE framework eff ectively addresses the issue (fi gure 1B). The second claim is that EBM encourages formulaic “cookbook medicine”,87 discouraging deliberation and clinical reasoning and leading to automatic decision making. This criticism was reframed in a recent article that raised the question of whether EBM is a “movement in crisis”, and issued warnings regarding approaches that are excessively algorithmic (in the process, perhaps neglecting the frequent usefulness of algorithms).88 The critics have noted that care for a particular patient “may not match what the best (average) evidence seems to suggest.”88 These88 and other authors89 lament that EBM has neglected the humanistic and personal aspects of medical care and moved the focus away from the individual.90 In reality, EBM has aggressively promoted the need to consider a patient’s values in every preference￾sensitive decision.91 A focus on individual patient values, which involve how patients view the world and their relationships with their environment, friends, and loved ones, lies at the heart of the humanistic practice of medicine. Notably, from its early days, EBM has focused on the individual patient. Aspects of that focus included championing randomised trials in individual patients (N-of-1 randomised trials),92 highlighting diff erences in baseline risk (large eff ects in patients with high baseline risk and small eff ects in those with low baseline risk), and providing guides for the credibility of subgroup analysis.93 A third criticism is that EBM promotes rule-based reasoning instead of intuitive and experiential thinking, which characterise expert judgment.88 EBM has indeed maintained that scientifi c evidence should refl ect knowledge that is publicly shared and easily understood by all qualifi ed professionals in the fi eld.16 It is understandable that EBM’s stress on the use of results of replicable research could be interpreted as diminishing the role of expertise and judicious clinical judgment. EBM does, in fact, highly value the critical role of expertise in health-care-delivery by emphasising the importance of judicious judgment in critical appraisal and decision making. Another criticism of EBM is that there is no high￾quality evidence that its application has improved patient care. We would rebut by noting the history of a decade-or￾more delays in implementing interventions, such as thrombolytic therapy for myocardial infarction,94 and highlighting the previously described examples of routinely administered useless and harmful interventions, such as lidocaine to patients after myocardial infarction, placing infants on their stomachs to sleep, or hormone replacement therapy for postmenopausal women, that preceded the widespread implementation of EBM. Recent writings have also claimed that EBM has been “high-jacked”95 by commercial interests that, having learned how to exploit EBM principles, have been creating doubt when none reasonably exists,96 spinning the message,97 and medicalising issues that are better