Improving Quality in Surgery: Looking to Evidence-Based Medicine

Are surgeons less likely to embrace evidence-based medicine (EBM) and use cutting-edge research methods to conduct high-quality randomized, controlled trials than their medical colleagues? That’s been suggested more than once by seemingly more avant-garde fields of medicine. In an editorial in the International Journal of Surgery, this issue is explored at length. The author looks at the triad of EBM: surgeons’ clinical expertise and ability to self-examine, the best available external evidence from systematic research and patients’ values, preferences and expectations.

This editorial argues that by eschewing EBM due to the frequently urgent nature of surgery, surgeons fell behind other fields in adopting this tool, citing studies that prove this point; many surgical journals published few randomized, controlled studies until recently. The result has been that about half of surgical patients still receive non-EBM treatments.

That problem has been somewhat rectified with journals publishing more and better quality studies, but there is ample room for improvement. Many surgical journals have introduced EBM Section, but surgeons need to review new findings routinely and implement them into practice.

The author identifies several inherent obstacles for EBM in surgery, including randomization and blinding, and the concept that the individual who evaluates outcome is often the surgeon himself—problems that introduce bias into many findings. In addition, many surgeons lack training in biostatistics and study design, and ethical issues are more difficult to address in surgical studies than in many other specialties.

Eight potential solutions are proposed, and here, it appears that surgery is poised to capitalize on other medical specialties’ experiences:

• Educating surgeons on how to structure and conduct randomized , controlled studies
• Creating uniform funding sources
• Identifying most pressing needs for data
• Creating multi-center trials that can adequately blind trials
• Offering incentives to potential study subjects
• Addressing ethical issue in a forthright manner
• Looking for alternative study designs when RCT is not feasible, and
• Requiring compulsory study of new surgical technique

Surgeons will see more EBM in journals, and can look forward to seeing the surprises it brings—changes to techniques, realizations that procedures that seemed straightforward are not, and best of all, innovation.