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When strong research evidence supports a low risk intervention that is easy to implement, the practice of medicine may seem straightforward. The decision, for instance, to prescribe a β blocker for a patient who has had a myocardial infarction is generally clear cut. However, as the possibility of harm increases, the evidence for efficacy diminishes, or the steps to implementation become more complex, challenges abound. Deciding whether to recommend adjusted dose warfarin in a 75 year old man with newly diagnosed atrial fibrillation and a previous history of stroke can become nearly overwhelming as we delve into the particulars of his life: that he recently relocated to a second floor flat after his wife died and has slipped on the stairs twice; that his daughter will be moving in with him to help out, but not for 6 months; that he can only arrange transport to the clinic to get his international normalised ratio checked bimonthly; and that he is also taking amiodarone, which will make dosing more difficult. We may opt to talk with his daughter to see if she can come sooner, to his cardiologist to determine if he can substitute another antiarrhythmic, and to the visiting nurses association to see if they can monitor him in his home. Our plan of care will evolve as we factor in these options.
Unless we ask the right questions, we are likely to miss the contextual issues that are so often essential to care. Even in apparently straightforward cases such as the initiation of β blocker therapy described above, recognising that a …