Will the Dilemma of Evidence‐based Surgery Ever Be Resolved?

Abstract

Exponents of evidence-based medicine do not undermine the importance of clinical expertise and skills, but they emphasize that decision-making in medicine should be based on the best available evidence derived from the systematic analysis of observations made in an objective, unbiased and a reproducible fashion. The randomized controlled trial (RCT) is the most scientifically rigorous means of hypothesis testing in epidemiology. Discrepancies between established surgical and other interventions and best available evidence are common. These can be in the form of significant delay in adopting a new intervention despite strong supportive evidence, adopting an intervention before supportive evidence becomes available for reasons of novelty or pear pressure and the lack of supportive evidence for many established common practices. This is compounded further by the paucity of good quality evidence for most surgical procedures. This is arguably because of the inherent difficulties in conducting surgical RCT. The practical, ethical and financial ramifications are complex and the nature of surgical disease often compromise the chances of success or completion of RCT. Carrying out surgical RCT may have more implications on the clinician's authority, autonomy and income and their results are more likely to be influenced by his/her expertise and competence than medical RCT. Furthermore, the success of surgical RCT is often jeopardized by very low recruitment rates. The aim of this study is to discuss the dilemma of producing evidence in surgery.

Time to rethink the role of the library in educating doctors: driving information literacy in the clinical environment

“…The scholar and librarian work through the patient problem and develop a searchable questionoften using the patient/problem, intervention, comparison, outcome (PICO) format-as well as search strategies. The practice of evidence-based surgery can be problematic; for example, randomized controlled trials are difficult to conduct in many surgical areas due to ethical and technical issues [15,16]. Scholars quickly become aware of these limitations and are encouraged to look for the best available levels of evidence when searching the surgical literature for patient care information.…”

The role of evidence-based medicine in neurosurgery

“…1 Only 5% of articles published in three major surgical journals in 1990 were RCTs, and of those a large proportion were found to lack the power to even detect large differences in therapeutic effects at a statistically significant level. 6 Of the remainder, a large proportion utilised poor analytical and methodological techniques. Rothoerl et al have suggested that a high proportion of neurosurgical publications have only a low level of evidence.…”

“…There are many examples of guidelines that have been shown to reduce mortality and morbidity in surgical patients. 6 2.2. 'Surgery is not amenable to EBM because it is just as much an art as it is science'…”

“…10 Surgical RCTs are inherently difficult to perform because of ethical and funding considerations, difficulties using sham controls, problems with patient accrual (particularly where there is a small sample size), and preferences and variability in surgical proficiency and techniques. 6,11 Some surgeons may wish to avoid RCTs to avoid the risk of having their innovative procedures deemed ineffective. 12 Such an attitude clearly represents a conflict of interest between patient and surgeon.…”

“…Generally speaking, the implementation of a new therapy over currently available best practice requires the demonstration of improved efficacy or the same efficacy at reduced cost and risk with evidence of significant power. 6 The need for objective and powerful evidence to justify treatments for our patients needs however to be considered in the context of public demand for the latest in modern technological advances; the development of which could be significantly retarded if we were to demand the cumbersome requirements of class one evidence for each new device. 10 The methodology of EBM will need to evolve to meet the challenges of technologically driven specialties.…”