For centuries, new physicians have recited the Hippocratic Oath as they embark on their journey as clinicians. The Oath famously urges physicians to "do no harm," an edict that remains at the forefront of medical practice. The first mandate in the Oath, however, pertains not to patients, but to fellow practitioners. Hippocrates charges new physicians to pass their knowledge on to the next generation.
In the current era, medical practitioners face a novel problem. While Hippocrates raised concerns about the scarcity of teaching and potential loss of information, the rapid expansion of medical knowledge and enhanced availability through electronic media threatens to overwhelm trainees with content. New textbook titles accumulate almost weekly, hundreds of journals siphon articles directly onto our cellular phones, and easily accessible databases promise answers at our fingertips. Physicians can no longer concern themselves with dissemination only, but instead must focus on distillation, sifting for meaning amid an overwhelming volume of information.
Anyone who has worked in a surgical department understands the clinical repercussions of this embarrassment of riches. Dogma contests data. When studies conflict, some physicians change their practice, and some respond with stalwart adherence to tradition and routine. The conflicting practice patterns that result are a challenge for trainees. A resident may learn about prescribing Gastrografin to shorten the duration of an adhesive small-bowel obstruction from one attending surgeon, only to be chastised for suggesting the same treatment to another. One hospital routinely gives octreotide for pancreatic fistulae, while another does not keep the drug on formulary. In the operating room, is a pylorus-preserving Whipple procedure oncologically equivalent? What margins are necessary for a thin melanoma? Uncertainty infiltrates even minor decisions: Why is a surgeon adamant about the superiority of chromic gut over monocryl for skin closure? Why is IV acetaminophen preferred over ketorolac for postoperative pain? In some cases, the rationale behind these decisions is rooted in preference; in others, anecdote; and in still others, careful review of the literature.
During residency, surgical trainees develop habits that will guide them throughout their professional careers. More important than adopting any one preference over another is the method by which we choose our preferences. The data are not always conclusive, and studies are not always well designed. But surgical trainees must learn to discern among the conflicting influences of tradition and evidence in order to make clinical decisions.
This book is not intended as a textbook, or a surgical journal. This book is meant to guide you toward a practice grounded in evidence, and to enhance your ability to find and evaluate new information. Reach for this book before starting a new rotation. Reference it when asked to discuss an article at a journal club or lunchtime talk. Most importantly, remember it when you're asked to prescribe a medication, use a specific technique, or choose a certain procedure "because that's the way we do it here." Use it to determine, for yourself, the best care possible, and use it to continually challenge those decisions as you encounter new data throughout your career.