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2020 Means Better Decisions

By Amar A. Patel, MD

How do surgeons make decisions?

I recently had a discussion with some close friends from medical school (physicians spanning from primary care to medical and surgical specialties). A few frustrated friends in particular brought up something that really resonated with me: Surgery (including hand surgery, orthopedic surgery, and plastic surgery) has limited evidence-based medicine (EBM) to back up many current practices. I tried to defend my surgical peers by combing through recent studies and meta-analyses to justify the decisions we make and how we make them. But even for routine problems (such as ganglion cysts of the wrist, proximal phalanx fractures, and soft tissue coverage/ wound management) and simple questions (such as, “Is operative treatment superior to non-operative treatment?”), high quality evidence is often lacking!

The pertinent literature that we have is mired with retrospective reviews with relatively small cohorts, and larger studies often do not have any control groups for comparison. Large, multi-center, prospective, randomized, controlled, and blinded studies are considered the gold standard, but these are challenging to perform and few exist in our present literature. This does not mean our actions are harmful or a deviation from the standard of care, but it means that we perhaps need to re-evaluate the basis for our decision-making.

It is easy for a seasoned surgeon to exclaim “this has always worked in my hands” or “this is what I was taught” as a rationale for the treatment provided. There is no doubt that experience has value in providing a basis for much of our own decision-making. But with variations in decision-making or technique comes variations in quality of care, and providing the absolute best quality of care is ultimately our duty. In order to achieve this, we simply need more valuable research to be performed.

Hand surgery is a relatively small and new subspecialty, but I believe that the ASSH and the hand surgery community are already making EBM a priority. I commend our organization for the creation of the EBM committee over a decade ago and for the improvement in the quality and level of evidence in publications and scientific abstracts over that time. Continuing the momentum will help pave the way for better guidelines that current and incoming surgeons can use to provide the best possible care to their patients.

In 2020, I would like to see ASSH and the entire hand surgery community continue the charge for obtaining and utilizing the best EBM possible.

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