Posted on April 28, 2014
Evidence-based surgery is needed, however surgery is different with regards to designing research studies.
My first experience with evidence-based medicine [i] [ii] was during a lecture in med school. We talked about how great it would be if doctors could make decisions based on their clinical experience and scientific knowledge to provide tailored decisions with regards to each individual patient and their personal preferences and characteristics. This sounded almost too good to be true. You might have thought of a few general challenges. First of all it is quite hard to keep up to date with science, secondly not every paper is of the best quality and thirdly how can we distill individual predictions or expectations out of the reported group results. All the more reason to increase our knowledge on evidence-based practice and improve our skills in tackling these challenges.
With support for evidence-based medicine growing we would expect an increasing amount of randomized controlled trials (RCTs), being regarded as the golden standard in scientific medical research. In surgery however, the frequency of published RCTs remain low. [iii]
The Balliol Collaboration and later on the IDEAL Collaboration amongst others reported possible explanations for RCT’s being few in number within the surgical field. They additionally reported shortcomings in methods and reporting quality. It might be due to challenges specific for the surgical field, for instance surgical interventions are more complex due to different in-hospital surgery teams as well as different practice in post-operative care. This provides challenges in terms of comparability and leads to subjective decisions whether differences are substantial enough to standardize. Also, regulations with regards to surgical innovations are less strict, leading to a higher innovation speed which in term leads to difficulty in timing the right moment to start a trial.
In a search to gain more insight in evidence-based medicine within the field of surgery I stumbled upon the IDEAL Collaboration website (http://www.ideal-collaboration.net), an initiative to improve quality of research in surgery and started reading the articles. The articles provided a clear insight in possible explanations why RCTs are not common practice within the surgical field when compared to drug research, ranging from complexity and innovation speed to historical differences and less strict regulations. Furthermore it provides advices to address these challenges.
The IDEAL Collaboration helps provide insight in specific challenges that are present within the field of surgery. Knowing these challenges will help you to critically appraise (surgical) articles as well as provide a guiding framework while setting up your own trial.
I can recommend the IDEAL Collaboration website and articles to everyone, whether you are surgically orientated or not.
I do hope the overall quality of surgical research will keep improving. Methodologically sound RCT’s are needed to improve the quality of surgical research as well as help evaluate innovations and techniques. Both will contribute towards an evidence-based practice. The combination of recommendations from the IDEAL Collaboration and society’s need for evidence-based practice combined will hopefully pave the way for evidence-based surgery.
[i] Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. 1996. Evidence based medicine: what it is and what it isn’t. BMJ 312: 71–2 [3