Introduction

Fig. 1.1

PubMed entries with keywords ‘evidence based medicine’

Without a doubt evidence-based medicine provides surgeons with a rational basis to support guidelines for treatment modalities and contributes to standardization of care, which in many instances results in improved quality of care and better patient outcomes. But with the guidelines may come an unwelcomed restrictiveness; many surgeons are reluctant to alter their practice and may have very legitimate concerns whether the generalized evidence really provides the best solution for the individual patient. The interpretation of data as presented in medical literature may require the reader to become ‘information literate’ to appraise the quality of the evidence and its true applicability to the individual surgeon’s practice.

Introduction of new technology into colon and rectal surgical practice is resulting in a rapidly expanding technical armamentarium. Some surgeons self-described as “early adaptors” are quick to jump on the bandwagon to embrace new and often unproven technology, driven by a general desire to advance the field and push the envelope. An unbiased and thoughtful review of data and careful reflection on the ethical considerations based on the surgical dictum of “do no harm” should be liberally exercised.

Bringing It Together

Initially, EBM focused primarily on determining the best evidence and applying that evidence to the clinical situation at hand. This early approach lacked emphasis on traditional aspects of clinical decision-making such as physiologic rationale and individual clinical experience. Fortunately, with evolution of EBM came the realization that research-based evidence alone may not be an adequate guide to action. Instead, clinicians must combine their experience, the applicable scientific evidence and the patient’s wishes and values before making a treatment recommendation. Figure 1.2 depicts a model for evidence-based decisions, which emphasizes “clinical expertise” as an overarching component in EBM decision-making. Clinical expertise encompasses the patient’s clinical state and surrounding circumstances, combining it with relevant research evidence, and the patient’s preferences. Getting the diagnosis and prognosis right and knowing how to provide treatment demand more skill now than ever before because the options are many and patient expectations are high. Surgeons in the current clinical environment must be abreast of not only the scientific evidence; they must also acquire and hone skills needed to both interpret the evidence and apply it appropriately in clinical settings. Finally, and very importantly, the patients’ goals, values and wishes remain the cornerstone to the best and informed decisions [7].