Discussion Discussion: Perceptions of the Risks and Benefits of Upper Limb Transplantation among Individuals with Upper Limb Amputations Warren C. Breidenbach, M.D., M.Sc. Edward A. Meister, Ph.D.† Kareem Hassan, B.A. Tucson, Ariz.
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his study by Jensen et al. is an important step forward in developing an understanding of the psychological and functional factors that influence the decision of hand amputation victims for and against hand transplantation.1 To understand the significance of this article, it is imperative to understand grounded theory. Grounded theory is both a theory and a methodology. As a theory, grounded theory states that one can develop potential hypotheses by questioning a selected group of individuals. As a methodology, grounded theory establishes rules as to how these questions are developed and collated. The authors’ use of grounded theory aims to elicit the essential risks and benefits for the patient by questioning the patients themselves.2 This stands in contrast to the traditional study methodology of surveying physicians who propose the important hypothesis by attempting to empathize with the patients. In this study, a defined cohort of individuals with amputations was questioned about their preferences. From their responses, a hypothesis can be generated. There are certain facts about grounded theory for clinicians to keep in mind while reading this article, especially for those who are unfamiliar with qualitative research. One is that grounded theory aims at hypothesis creation, rather than confirmation. The aim of grounded theory is to find out what is important, rather than how important it is. For example, regarding the interpretation of the data from the article by Jensen et al., one cannot say that men value appearance more From Reconstructive and Plastic Surgery and the Department of Medicine, Division of Transplantation, University of Arizona. Received for publication July 7, 2014; accepted July 11, 2014. †Deceased. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000690
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than women, 70 percent versus 30 percent, respectively, simply because a higher proportion of men identified appearance as a benefit of transplantation.1 Rather, Jensen et al. inform us that this is an important theory to confirm. To validate the newly developed theory from these data, a more traditional study must be performed. In Table 3, six areas of potential benefit from hand transplantation are identified. The early pioneers in hand transplantation anticipated all six of these areas of potential improvement without the use of grounded theory, but not the multiple subcategories of amputee preferences identified by Jensen et al.3,4 This insight makes the article an important contribution because it identifies new areas for further study in hand transplantation. In may appear this study lacks equal distribution among sex, ethnicity, and socioeconomic levels. However, as mentioned in the article, in qualitative research the most essential aspect of the sampling criteria is knowledge of, or experience in, the subject matter, rather than demographics.5 Another potential weakness is that some participants in the study had no knowledge of limb transplantation. However, all subjects shared the experience of amputation and were able to express their own perceptions regarding limb transplantation. Lastly, the authors claim the sample size of 22 achieved saturation. Theoretical saturation in qualitative data analysis means the researcher has continued sampling and analyzing data until no new data appear and all concepts in the theory are well developed. Jensen et al. provided no indication of their threshold for saturation of responses.1 Although some have hypothesized Disclosure: The authors have no financial interest to declare in relation to the content of this Discussion or of the associated article.
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Volume 134, Number 5 • Discussion that such a number of interviews could generate 90 to 95 percent of the factors important to a population, in-depth interviews are required.5 The importance here is that although saturation may have been achieved for responses regarding function of the transplantation, further exploration into the definition of function may have generated further data.6 Although the sample size is likely sufficient for the purposes of qualitative research, further details on the criteria for saturation are warranted. Overall, this work is to be applauded for its attempt to break down potential misconceptions physicians hold regarding the psyche of amputation victims regarding limb transplantation. This study should help us in developing new studies to validate the preferences of potential hand transplant patients. Warren C. Breidenbach, M.D., M.Sc. Division of Reconstructive and Plastic Surgery Department of Surgery University of Arizona P.O. Box 245062 Tucson, Ariz. 85724-5062 [email protected]
ACKNOWLEDGMENT
Dr. Ed Meister was a statistician at the University of Arizona, and a significant contributor to this Discussion. It was his last statistical work to this world. He died suddenly as we were finishing this review. He contributed greatly to our research efforts here at the University of Arizona. He will be greatly missed. REFERENCES 1. Jensen S, Butt Z, Heinemann AW, et al. Perceptions of the risks and benefits of upper limb transplantation among individuals with upper limb amputations. Plast Reconstr Surg. 2014;134:979–987. 2. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine; 1967. 3. Bryant A, Charmaz K. The SAGE Handbook of Grounded Theory: Paperback Edition. Thousand Oaks, Calif: Sage; 2010:232–233. 4. Breidenbach WC III, Tobin GR II, Gorantla VS, Gonzalez RN, Granger DK. A position statement in support of hand transplantation J Hand Surg Am. 2002;27:760–770. 5. Vorberg D, Ulrich R. Random search with unequal search rates: Serial and parallel generalizations of McGill’s model. J Math Psychol. 1987;31:1–23. 6. Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. Thousand Oaks, Calif: Sage; 2006.
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T
his study by Jensen et al. is an important step forward in developing an understanding of the psychological and functional factors that influence the decision of hand amputation victims for and against hand transplantation.1 To understand the significance of this article, it is imperative to understand grounded theory. Grounded theory is both a theory and a methodology. As a theory, grounded theory states that one can develop potential hypotheses by questioning a selected group of individuals. As a methodology, grounded theory establishes rules as to how these questions are developed and collated. The authors’ use of grounded theory aims to elicit the essential risks and benefits for the patient by questioning the patients themselves.2 This stands in contrast to the traditional study methodology of surveying physicians who propose the important hypothesis by attempting to empathize with the patients. In this study, a defined cohort of individuals with amputations was questioned about their preferences. From their responses, a hypothesis can be generated. There are certain facts about grounded theory for clinicians to keep in mind while reading this article, especially for those who are unfamiliar with qualitative research. One is that grounded theory aims at hypothesis creation, rather than confirmation. The aim of grounded theory is to find out what is important, rather than how important it is. For example, regarding the interpretation of the data from the article by Jensen et al., one cannot say that men value appearance more From Reconstructive and Plastic Surgery and the Department of Medicine, Division of Transplantation, University of Arizona. Received for publication July 7, 2014; accepted July 11, 2014. †Deceased. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000690
988
than women, 70 percent versus 30 percent, respectively, simply because a higher proportion of men identified appearance as a benefit of transplantation.1 Rather, Jensen et al. inform us that this is an important theory to confirm. To validate the newly developed theory from these data, a more traditional study must be performed. In Table 3, six areas of potential benefit from hand transplantation are identified. The early pioneers in hand transplantation anticipated all six of these areas of potential improvement without the use of grounded theory, but not the multiple subcategories of amputee preferences identified by Jensen et al.3,4 This insight makes the article an important contribution because it identifies new areas for further study in hand transplantation. In may appear this study lacks equal distribution among sex, ethnicity, and socioeconomic levels. However, as mentioned in the article, in qualitative research the most essential aspect of the sampling criteria is knowledge of, or experience in, the subject matter, rather than demographics.5 Another potential weakness is that some participants in the study had no knowledge of limb transplantation. However, all subjects shared the experience of amputation and were able to express their own perceptions regarding limb transplantation. Lastly, the authors claim the sample size of 22 achieved saturation. Theoretical saturation in qualitative data analysis means the researcher has continued sampling and analyzing data until no new data appear and all concepts in the theory are well developed. Jensen et al. provided no indication of their threshold for saturation of responses.1 Although some have hypothesized Disclosure: The authors have no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
Volume 134, Number 5 • Discussion that such a number of interviews could generate 90 to 95 percent of the factors important to a population, in-depth interviews are required.5 The importance here is that although saturation may have been achieved for responses regarding function of the transplantation, further exploration into the definition of function may have generated further data.6 Although the sample size is likely sufficient for the purposes of qualitative research, further details on the criteria for saturation are warranted. Overall, this work is to be applauded for its attempt to break down potential misconceptions physicians hold regarding the psyche of amputation victims regarding limb transplantation. This study should help us in developing new studies to validate the preferences of potential hand transplant patients. Warren C. Breidenbach, M.D., M.Sc. Division of Reconstructive and Plastic Surgery Department of Surgery University of Arizona P.O. Box 245062 Tucson, Ariz. 85724-5062 [email protected]
ACKNOWLEDGMENT
Dr. Ed Meister was a statistician at the University of Arizona, and a significant contributor to this Discussion. It was his last statistical work to this world. He died suddenly as we were finishing this review. He contributed greatly to our research efforts here at the University of Arizona. He will be greatly missed. REFERENCES 1. Jensen S, Butt Z, Heinemann AW, et al. Perceptions of the risks and benefits of upper limb transplantation among individuals with upper limb amputations. Plast Reconstr Surg. 2014;134:979–987. 2. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine; 1967. 3. Bryant A, Charmaz K. The SAGE Handbook of Grounded Theory: Paperback Edition. Thousand Oaks, Calif: Sage; 2010:232–233. 4. Breidenbach WC III, Tobin GR II, Gorantla VS, Gonzalez RN, Granger DK. A position statement in support of hand transplantation J Hand Surg Am. 2002;27:760–770. 5. Vorberg D, Ulrich R. Random search with unequal search rates: Serial and parallel generalizations of McGill’s model. J Math Psychol. 1987;31:1–23. 6. Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. Thousand Oaks, Calif: Sage; 2006.
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