So You Want to Be Better: The Role of Evidence-Based Medicine in Plastic Surgery

Expert capability and status in surgery is a worthy goal. However, what can the accomplished plastic surgeon do to become even better than “expert”? We dare not rest on our current status, even if that status is “expert.” The irony is that when one looks at where we want and need to be by evidence-based medicine standards (Tables 1 and 2), the expert is at the bottom of this scale! How can this be? Plastic surgery historically has been ruled by “expert” thought or expert opinion. Whether or not this is right, it simply is the fact of the matter. This situation has been good initially for our specialty, as it has been for all surgical specialties. However, now we need to go to the next level, that of elevating all of plastic surgery to a more evidence-based medicine scale to prove we are indeed better. “Better than who” or “better than what” are often-asked questions. First and foremost, we need to be better than we were before, as individuals and as a specialty, and show this in a data-driven manner using systematic reviews and randomized controlled trials. How can we do this? We must not become complacent, satisfied at a set level of competency or ability within our profession. I am convinced that we must always move forward and become better; if we are not moving forward, we are moving backward. Given this conviction, how does one become a better plastic and reconstructive surgeon in the era of evidence-based medicine? There are at least five primary ways that each of us can become better. I will touch on four in a cursory fashion, and discuss the fifth as the primary way each of us as individuals and our specialty can improve and become better in the future.Table 1: Evidence Rating Scale for Studies ReviewedTable 2: Scale of Grading RecommendationsThe first way we can become better is to continue to stay up-to-date in our given subspecialties, whether it is by going to meetings, reading Plastic and Reconstructive Surgery, or becoming a plastic surgeon with new or additional expertise in a new area of interest. Alternatively, we can take a course in some new area of plastic surgery with which we are not familiar. Taking courses can revitalize you and provide you with the latest information on issues you do not ordinarily deal with, such as a different aspect of science. Broadening your horizons, interests, and competencies will make you better in every field of endeavor, including your surgical practice. Different fields of study could certainly include different surgical or nonsurgical medical areas, such as radiology, oncology, and internal medicine. What will broaden you even more, however, is enriching yourself in a non–medicine-related field of study. Are you interested in history? Take a class that intrigues you. There is great value in such courses themselves and perhaps equally great value in meeting new colleagues in a completely new field of medicine. As an important subset of continuing education courses, I highly recommend taking refresher anatomy courses. Focus either on the anatomic areas of your subspecialty or on the entire body. I am convinced that we cannot spend too much time learning and relearning gross and specific human anatomy. Having an encyclopedic knowledge of human anatomy, along with its nearly limitless variations and nuances, will only make us better surgeons. A third way we can become better is to become teachers or instructors, if we have not already done so. I have found that I learn vastly more by being a teacher than I ever did by being a student. Teaching requires us not only to learn our subject matter well but also to be able to apply it appropriately and skillfully. As a student, I had to answer questions in a more or less static, stale manner. As a teacher, I have to be better; I have to be able to think of questions, pose problems, and provide ready solutions to any number of different situations or scenarios that may arise. I became competent as a student, but I became a master as a teacher. I encourage you to join on as an instructor, teacher, or mentor with your local plastic surgery department or service in the hospital. You will not only become better yourself, you will help train the next generation of plastic surgeons to be better as well, and you will enrich them with your own repository of knowledge and skills. A fourth way for us to become better is to take a break from our labors to take time to reflect. What I am advocating in this reflection is an “active break” from our normal routines and activities. We will improve as surgeons if we occasionally cease our hectic paces and reflect, review, evaluate, and learn from what we have done. The book of Genesis says that on the seventh day, God ceased from creating and rested, looking back and enjoying all He had created. Not only was it good, but it was “very good.” We, too, will benefit from looking back on what we have done. We should take time not only to recognize and take pride in our work but also to study what we have done, distilling lessons, seeing what worked, understanding what did not work, and applying such new learning to our practices. This practice of evaluating your work leads to the best, most scientific and objective way to become better in plastic surgery, the practice of evidence-based medicine. Everyone wants to be better. Each of us makes errors in medical care, and yet we can learn and improve from these errors to become better; the key to higher quality is continuous improvement. A far better way is to learn from the clinical experience and expertise of other groups doing clinical work–-evidence-based medicine. Today, being better means that we need to use the best available evidence employing the scientific method to make proper medical decisions without making medical errors. The goal is to seek the quality and evidence of the risks and benefits in treatments. Of course, evidence-based medicine has been around a long time, but it has been a late-comer to surgery, especially plastic surgery.1 We recognize the many aspects of medical care depend on factors such as quality and value of life judgments, which are obviously very important in plastic surgery but only partially subject to the scientific method. Evidence-based medicine is the key that helps to clarify the parts that are subject to the scientific method and apply those methods to ensure the best prediction of outcome, even if debate continues about which one is the best. In this way, we reduce medical error and learn from others' mistakes, not just our own. Evidence-based medicine has come a long way to enhance and make medicine better, but does it make the individual practitioner better? Do we still want to practice evidence-based individual decision-making, which is basically the lowest and least scientific level of evidence, that of an expert's opinion? The entire spectrum of plastic surgery procedures and “how to” has been driven by expert opinion; however, in most aspects of what we do, the experts have set the tone for plastic surgery since the beginning. Now is the time to change and be better. THE DEFINITION OF EVIDENCE-BASED MEDICINE Let's review the different levels of evidence-based medicine (Table 1).1 Plastic surgery and its history have thrived on the five levels of evidence. It has thrived on level 5 evidence, which is that of an expert. Experts have shaped the practice of plastic surgery to a large extent, especially in cosmetic surgery. To be blunt, those of us who have published the most and lectured extensively on a topic of our technique and expertise have shaped how we do techniques and currently how technology is moving forward! However, this is now faltering because, long term, we have learned that certain types of face lifts, breast surgery, or flaps may or may not be the optimal way to do things. Long term, they have not been shown to truly be the most efficacious method; in fact, in some cases they have more complications. We need to resort to things that work and are scientifically proven where we can use prospective studies or matched cohort groups (which is very difficult to do in plastic surgery, especially in cosmetic surgery). Even systematic reviews of published research data evaluating particular treatments have been used extensively in the Cochrane Collaboration, which is perhaps the best known example of systematic reviews. It is amazing that in a recent Cochrane Collaboration analysis published in 2007, of 1016 systematic reviews, 44 percent of reviews concluded that the intervention was likely to be beneficial, 7 percent concluded that the intervention was likely to be harmful, and 49 percent concluded that the evidence did not support the benefit or harm. Fully 96 percent recommended further research.2 This is truly astounding, so there are actually three different types of evidence-based medicine! The first approach is to treat patients who have acute or chronic pathology according to scientifically valid medical literature. In plastic surgery, this is very, very limited. Perhaps the exception is in the area of breast reconstruction, where we have some evidence-based medical data. The second is that of systematic review of the medical literature to evaluate the best studies on specific topics. The key is that you need to select the truly best articles that have excellent data and include data analysis of outcomes and complications. However, many publications in plastic surgery do not have sufficient data that can be validated for systematic review, especially if they only present expert opinion. Finally, evidence-based medicine has been understood to be a medical movement that advocates work to instill the scientific method into the practice of medicine to enhance public and patient safety as well as the physician's continual medical education to become and stay better. So what does this mean to us as practitioners in plastic surgery? I think we all need to take a giant step back on what is considered to be the “gold standard” in plastic surgery and what is truly the best way to practice plastic surgery for each of us. Specifically, is what has been published the truly correct way to do a free flap or face lift or the best way to optimize your patient's care and safety? The answer in most cases is, we do not really know. The key is to resort to “do no harm.” Do we have a way, a methodology, a study that shows that there is an effective and safe way of doing interventions or operative procedures in a clinically meaningful and safe manner for all patients? Recently, there has been an effort by the Intermountain Healthcare model led by Brent James on ways to improve our current health care system and which, in part, can answer the criticism of our health care system.3 However, we must recognize the limits of evidence-based medicine; what is good for a group is not necessarily equally good for each and every member of the group as a whole. In the near future, the American Board of Plastic Surgery may publish some of its Maintenance of Certification data related to practice quality, as well as trends in practice case medicine, to further analyze how plastic surgeons practice. Validating our medical care without evidence-based medicine will not allow us to achieve the same evidence-based safety and efficacy as those of our air transportation flight safety system. Humans can have highly variable physiology, medical conditions, recovery, and reactions to medicines and treatments; such factors sometimes vary dramatically, and medical care always eventually comes down to individualized medicine. The key is optimized patient safety/outcome, so we all can be better surgeons and provide objective standards of patient care. One of the problems in our health care system, as imperfect and yet excellent as it is, is the pervasive incentives in our current health care insurance system for hospitals and physicians, in that we are rewarded for performing as many procedures as possible. This rewards system, based on overall output, has a negative effect in that it punishes us for performing or improving outcomes. Better outcomes (for the individual and collectively) often take more time to achieve, involve more surgical and medical team effort, and thus negatively impact the “efficiency” of the system that focuses largely on volume of patient throughput. So how do you justify or even select the best options using these criteria? What does a hospital or a physician do if you have to choose between better care and higher hospital income? I guess that is an easy choice. We will only see in the future what it will hold for us, but evidence-based medicine is the key to our future if we truly want to become better–-better physicians, better plastic surgeons providing better patient care. ACKNOWLEDGMENT The author gratefully acknowledges the helpful comments and insight provided by Dr. Kevin C. Chung, PRS Section Editor for Outcomes, in the preparation of this article.