Orthopaedics must take a leadership role

The mission statement of the AAOS states, “The AAOS will serve the profession, champion the interests of patients, and advance the highest quality musculoskeletal health.”

To be active participants in this mission statement, I suggest that we, as orthopaedic surgeons, must all be actively engaged in changing the culture with regard to evidence-based medicine (EBM).

What is evidence-based medicine?
This can be answered in several ways. We can start by saying that EBM is NOT the inability to act or to treat patients without a randomized controlled trial that covers the patient’s particular situation.

EBM is a methodology used by well-trained clinicians that teaches or allows us to discern the best answer with regard to diagnosis or treatment of our patients. At the same time, the focus is on positive patient outcomes.

You may be thinking that this is what you always do. Multiple scientific investigations show that, in totality, this is definitely not the case. The culture within our beloved orthopaedic community must be changed. Multiple examples of orthopaedic patients receiving less-than-optimal treatment, based on their surgeon’s ignoring—or ignorance of—sound evidence, can be found.

The opportunities to change this culture are often subtle and require us to be willing to seek to make improvements in the care we provide to patients.

Consider the national agenda of healthcare reform. Part of the healthcare reform agenda is measuring effectiveness. Members of the AAOS hope that the national measures of effectiveness will be based on sound scientific principles. Changing our orthopaedic culture to more strongly embrace EBM will give us seats at those discussions.

Making progress
Let us consider some of our past practices:

• If you saw one patient, you’d say “in my experience.”
• If you saw a second, similar patient, you’d describe “in case after case.”
• By the time you saw a third patient, you might respond with something like, “in my case series.”

Today, we live in an increasingly complex world. Many critics are prepared to disparage our thoughts or decisions for a variety of reasons. Our best defense, or the high road, seems based in sound scientific methods.

The history of medicine is not based on marketing or deceitful practices. The best medicine is based on a solid foundation of scientific principles brought together in a cohesive package. Advances in anesthesia, aseptic techniques, diagnostic imaging, treatment of infections, and total joint arthroplasty surgery would not have been possible without careful and painstaking scientific investigations.

As our lives progress and our experiences grow, we realize a couple of certainties. The first certainty is that our knowledge base is being altered on a daily basis with new information and new facts. The second certainty is that putting these data to good use for improved patient care requires us to make choices. It is in the making of these choices that EBM can be helpful, especially in circumstances with conflicting data. EBM methodology describes how to turn a plethora of facts into solid recommendations that can be used to make reasoned decisions for the benefit of our patients.

In changing our culture to recognize EMB, we must carefully consider the principles of EBM in the following situations:

• at conferences
• in clinical meetings
• during hospital rounds
• when making clinic and emergency department visits
• in the operating room

In other words, we must take EBM principles into account on a daily and consistent basis. The following suggestions may be helpful:

• Think of EBM principles as you attend rounds or listen to presentations at meetings and conferences. Ask yourself: “What is the strength of recommendation that the presenter is making?” and “What is the level of evidence that the presenter is using?”
• Think of EBM as you care for patients. Is the newest treatment that your patient is asking for based on solid scientific evidence? Or is it is simply a way for someone to make a commission or a procedural fee without some certainty of contributing to a positive patient outcome?
• Ask the resident (or attending if you are the resident) about the level of evidence that supports a “clinical rule” or a clinical decision algorithm. This discussion needs to be thoughtful and based on mutual respect.

Remember that we, as orthopaedists and leaders, need to do this consistently and regularly. We must try not to deviate from good EBM hygiene.

One of my favorite sayings is, “I can’t hear what you are saying; your actions speak louder than your words.” If we learn and implement the principles of EBM, we will be heard in our hospitals, our state and national legislatures, and our local, state, and national medical associations. Our appetite for collecting data and our desire to organize them in a way that will help us treat our patients will be evident.

The AAOS Evidence-Based Practice Committee can help. The committee is very active in developing sound, relevant clinical practice guidelines. After these guidelines are developed, the committee actively disseminates this information broadly within the orthopaedic community. The committee is also interested in your feedback and especially in your suggestions for future relevant topics for new clinical practice guidelines.

In addition, the committee has assembled an extensive educational experience on Orthopaedic Knowledge Online relating to evidence-based practice. It could be your first step on the journey to implementing EBM in your practice.

Timothy Brox, MD, is a member of both the Evidence-Based Practice Committee and the workgroup to update the AAOS clinical practice guideline on osteoarthritis of the knee. For more information about the Evidence-Based Practice Committee, contact Fareeha Shuttari-Khan, MPH, staff liaison, at Shuttari@aaos.org