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Key Points

  • image Cognitive bias is inescapable, and limits the ability of both individual practitioners and the surgical field in general, to advance and improve in a scientific fashion. Evidence Based Medicine is an attempt to codify the process of interpreting experience, assessing the literature and translating it into practice.

  • image Dealing with and interpreting the vast amount of surgical literature available on the Internet can be daunting, and this task can be aided by the application of identified formats for executing online search. The PICO (Patient/Population, Intervention, Comparison and Outcome) format is a commonly used method for codifying online search.

  • image Not all literature or evidence is created equal. There exist various approaches, such as the Oxford Center for Evidence Based Medicine (CEBM) Levels of Evidence or the GRADE (Grading and Recommendations, Assessment, Development and Evaluation) system, that have been developed to provide guidance in assessing and reifying scientific literature.

  • image The conversion of evidence into clinical practice often manifests in the creation of clinical guidelines. As with all things related to evidence based medicine, not all guidelines are created equal, and therefore there are certain characteristics that can be used to evaluate the quality of a particular clinical guideline.

  • image There are specific challenges in the application of evidence based medicine to surgery, not least of which is the difficulty in performing a truly randomized clinical trial. The CONSORT (Consolidated Standard of Reporting Clinical Trials) guidelines were developed to serve as minimal recommendations for reporting randomized clinical trials.

  • image The well-known saying “There are lies, damn lies and then statistics” points to the recognition that statistical tools can be prone to misuse, and emphasizes the need to understand the appropriate application, limits of and interpretation of reported statistics.

  • image Evidence based medicine has not thus far been held to its own standards of evidence. Recognizing that available “evidence” is a constantly shifting landscape should warn one against the dangers of epistemic certainty, and further emphasizes the fact that surgical education is an ongoing and perpetual process.


The singular importance of this chapter rests on the following chain of reasoning:

  1. The state of surgical science and knowledge is constantly changing.

  2. The education of a surgeon is a continuous process.

  3. Surgeons need to know how to evaluate new surgical knowledge to maintain their education in order to best serve their patients.

  4. This chapter provides guidance as to how surgeons might navigate, interpret and apply this new knowledge.

Notably, this reasoning also applies to the process of acquisition of new knowledge itself, which explains why this inaugural chapter on evidence-based medicine is occurring in the 11th edition of this book. Recognizing the impermanence and fluidity of knowledge is a critical insight for the responsible surgeon, but so too is realizing that “good practice” cannot occur without reference points as to what should be done given the current imperfect state of knowledge. These dual ...

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