Neurosurgeons are, for the most part, technophiles: We love technology and technique in the operating room. We revere the art of technical surgery, yet we depend increasingly on devices that improve our technical abilities to see where we are, to sense the function of the tissue around our instruments, to be more precise in action. These devices make us better surgeons, but they cannot operate without us. A skilled surgeon must artfully employ his/her technical excellence if an individual patient with unique anatomy is to benefit from them. Technological development has not removed the art from operative surgery, but it has changed the skills needed. Our patients are better off because of the development of new technologies and our acquisition of the artful skills to employ them. The analogy to the techniques of evidence-based medicine is exact. Evidence-based medicine provides a set of techniques for improving the reliability of clinical decision making. It allows the neurosurgeon to be as demanding of the tools of clinical decision making as she is of the tools of operative surgery. The application of those decision-making tools requires as much artful interpretation as the skilled use of devices in the operating room. Consider two patients: an 83-year-old woman with diabetes, hypertension, mild Alzheimer’s disease, and gout and an otherwise healthy 43-year-old man with hyperlipidemia, who have asymptomatic 70% carotid stenosis. The results of a meta-analysis of carotid endarterectomy cannot be applied “off the shelf” with any expectation that both outcomes will be excellent. The availability of that information in the mind of a well-prepared neurosurgeon, however, makes an excellent outcome more likely than it was when contradictory dogma dominated the discussion between neurosurgeon and neurologist. One of the strangest complaints about evidence-based neurosurgery that we hear with some regularity from neurosurgeons is “it’s too hard.” This usually comes from someone who routinely clips basilar artery aneurysms or has just finished a 9-hour multilevel spinal decompression and instrumented fusion. Yes, evidence-based practice is rigorous, time-consuming, sometimes boring, sometimes very rewarding, and sometimes the outcome isn’t as good as we would like it to be. Sounds like brain surgery to us! How does one retain the art of medical decision making while taking advantage of the techniques of evidence-based medicine? How does one become a skilled surgeon? It all takes practice. The remarkable advances in information technology of the past decade have made real-time evidence-based practice possible. The advances of the next 10 years will make it efficient. It is now possible to access the National Guideline Clearing House on a handheld device (www.guideline.gov), locate the appropriate references, look them up through an online library, and read the full-text electronic version without leaving the bedside. The excuses for not doing so are rapidly being eliminated. It takes a bit more effort to apply quality criteria and critically analyze the evidence thus located, but this is where practice speeds the process. Many guides exist to help the practicing neurosurgeon acquire these skills. They, too, are available online and are, for the most part, freely available (Doing EBM, http://www.cebm.net/using_ebm.asp; User’s Guide to Evidence-Based Practice, http://www.cche.net/usersguides/main.asp). For most important types of study, the answers to a few relatively simple questions can either inspire confidence or create doubt about the results reported in a clinical study or synthesis of clinical data. Familiarity with the concepts and questions will make evaluation quicker and more reliable. It remains only for the neurosurgeon to commit to demanding the same quality in the information that supports his or her clinical decisions as she or he requires in the technology that supports the application of surgical technique to the patient’s treatment. To do less is to be “just a technician” and to run the risk of skillfully doing the wrong thing. Many neurosurgical decisions are difficult. Too often, however, they are difficult because we do not know enough about the problem we are treating to make them easy. Those decisions must still be made. Lack of evidence should never be an excuse for therapeutic paralysis. Too often, however, rather than doing the hard work necessary to find the evidence that makes a hard decision easier, we find an easier way to make the decision. For years, we used a variety of “diagnostic” studies to decide which patients who have normal pressure hydrocephalus should be treated with a shunt. None of these tests has been shown to be reliable: They did not provide evidence that made a good outcome more likely.1 They did, however, provide a mechanism by which a decision could be made. The tests provided more benefit for the surgeon (providing an easy way to make a hard decision) than for the patient. An evidence-based understanding of such tests helps the surgeon avoid the waste of time and resources and false confidence such tests can provide. Each decision should be informed by the best-available evidence, but when that is insufficient, the neurosurgeon relies on training, experience, and knowledge of basic principles to arrive at a best guess for the patient’s individual situation. The goal of evidence-based neurosurgery is to be sure that best evidence is available and used, and that the lack of evidence is identified. It should also be the goal of every neurosurgeon to develop evidence of high quality to fill the gaps. Good evidence makes good decision making easier. Evidence-based neurosurgery is about making hard decisions easier, not finding an easy way to make hard decisions. Those who fear that evidence-based medicine will produce “cookbook” medicine both misunderstand the nature and goal of evidence-based medicine and greatly overestimate the ability of medical science to provide precise answers to individual patient clinical problems. Evidence is necessarily based on accumulated information, either from groups of similar patients or from the same patient at different times. The process of grouping, averaging, and summarizing can lead to sound principles of practice, but cannot anticipate every unique combination of circumstances that may confront patient and clinician. The art of neurosurgical practice is in dealing with those unique combinations of circumstance and applying the principles of decision making that have been clarified by evidence to the individual. Individualization of patient care is critically important, but it is the final stage of application of general principles. Evidence-based medicine will never replace the unique role of the physician in interpreting and applying evidence. It will inform, however, the physician’s decisions, making them more precise and reliable. The most artful neurosurgeon will also be the best informed. Beware, however, when the discussion of how to diagnose or treat a specific condition is dominated by statements that “patient care must be individualized” or “good clinical judgment is more important than any diagnostic test” rather than summary statements of best-available evidence followed by discussion of the nuances of applying that evidence. This situation generally accompanies a situation that is poorly studied, poorly understood, and requires more educated guessing than artful application of scientific principles. All who practice our profession should view the continuous enhancement of the quality and quantity of evidence that supports clinical decision making in neurosurgery with anticipation. Good evidence makes some decisions easier and casts light on other important questions that remain to be answered. It allows us to focus on the details of individual illness that inform the artful application of well-established principles rather than having to fret about important therapeutic questions for which there should be, but are not, clear answers. It makes us better doctors. We will always have insufficient evidence to answer all the questions that confront us. At the same time, we will always accumulate more knowledge about the diseases we treat. Lack of evidence is an opportunity to learn and advance our profession. It can also be a danger if we treat it as an opportunity to impose our personal opinion rather than do the work necessary to find an answer. We must not use the lack of evidence as either a license to treat in an untested, uncontrolled way or an excuse to not attempt to alleviate suffering: We must be neither liberated nor paralyzed by lack of evidence. In the end, the evidence-based practice of neurosurgery, done with compassion, compulsion, and commitment brings the best of science to inform the art of medical decision making, which, blended with technical and technological excellence, leads to the best possible outcomes for our patients.
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Evidence-Based Neurosurgery in Practice: Blending Art and Science
Stephen J. Haines
Evidence-Based Medicine: The Operating Microscope of Neurosurgical Decision Making
Art in Surgery Requires Practice
Making Hard Decisions Easier
Good Cooks Use Cookbooks, but Cookbooks Do Not Make Good Cooks
Continuous Improvement
Reference
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