doi:10.1111/codi.12559
Editorial
Why do we do the same things so differently? As medical students we all learnt ‘first do no harm’. This lesson follows us throughout the whole of our professional lives, and as surgeons we have to think about it almost every day. It is also said that ‘the greatest art in surgery is to keep your hands in your pockets’. While these general rules may be important guidelines, it is also obvious that in many situations we have to implement some form of intervention on behalf of the patient. However, what to do may not always be totally clear. We have all experienced the discussions of consultants’ corner sessions at meetings, where for even the commonest condition wide differences may be expressed over what the best clinical pathway should be. In the modern era of evidence-based medicine increasing efforts are being made to seek the best scientific basis for decisions of when and how to intervene. In this respect the non-surgical specialities are in the lead. The reason for this might be that it is scientifically much easier to create evidence or to reveal the absence of evidence for the benefit or otherwise of a medical intervention than for a surgical one. In addition the influence of the pharmaceutical industry in ‘helping’ to marshal and disseminate the available evidence may also play a part. For surgeons, decisions taken in an individual capacity are their own and their responsibility. Their choice is based on many factors, including the conditioning resulting from early education, what has been learnt from mentors and what is recommended by the guidelines, whether local or national. Guidelines are not prescriptive and, surprisingly, many on the same subject may vary considerably from country to country and even within a country from one scientific society to another [1]. This could be an explanation for diversity in the choice of treatment, when this occurs. This issue of Colorectal Disease contains an interesting paper [2] in which a survey amongst rectal surgeons has shown a wide variation in decision-taking in advising a diverting stoma after a colorectal anastomosis. One of the reasons for this could be related to the unquantifiable willingness of the more experienced surgeons to ‘take a chance’ and avoid a stoma to a greater
degree than others. One could argue that such differences in attitude are a feature of human nature and a reflection of individual variation. Only if solid evidence is available can this factor be diminished, and when it is the patient’s best interest lies in following it. Indeed in the presence of clear-cut evidence all other alternatives would be unacceptable. There is still a long way to go before the variance in practice based on non-objective factors gives way to evidence, and it may be many years before the application of scientific progress is fully incorporated into daily practice. Thus, although the scientific evidence for the protective value of a defunctioning stoma is well established [3] there is still a difference in opinion on when it should be performed. Of course every study leading to increase in the body of scientific evidence should be questioned scientifically according to methodological criteria, but several instruments now exist to evaluate the quality and level of evidence: examples include the Levels of Evidence table from the Oxford Centre for Evidence Based Medicine, the Newcastle Ottawa score and the Jadad score. The most important reasons for not doing the same thing are still the lack of Grade 1 evidence and individual interpretation of existing evidence.
Peer Wille-Jørgensen Digestive Disease Center, Bispebjerg Hospital, Copenhagen, Denmark
References 1 Augestad K, Lindsetmo R-O, Stulberg J et al. International Preoperative Rectal Cancer Management: staging, neoadjuvant treatment, and impact of multidisciplinary teams. World J Surg 2010; 34: 2689–700. 2 MacDermid E, Young CJ, Young J, Solomon M. Descision-making in rectal cancer surgery. Colorectal Dis 2014; 16: 203–8. 3 Matthiesen P, Hallbo O, Rutegard J, Dahl RSJ. Population-based study of risk factors for postoperative death after anterior resection of the rectum. Br J Surg 2006; 93: 498– 503.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 155
155
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial
Why do we do the same things so differently? As medical students we all learnt ‘first do no harm’. This lesson follows us throughout the whole of our professional lives, and as surgeons we have to think about it almost every day. It is also said that ‘the greatest art in surgery is to keep your hands in your pockets’. While these general rules may be important guidelines, it is also obvious that in many situations we have to implement some form of intervention on behalf of the patient. However, what to do may not always be totally clear. We have all experienced the discussions of consultants’ corner sessions at meetings, where for even the commonest condition wide differences may be expressed over what the best clinical pathway should be. In the modern era of evidence-based medicine increasing efforts are being made to seek the best scientific basis for decisions of when and how to intervene. In this respect the non-surgical specialities are in the lead. The reason for this might be that it is scientifically much easier to create evidence or to reveal the absence of evidence for the benefit or otherwise of a medical intervention than for a surgical one. In addition the influence of the pharmaceutical industry in ‘helping’ to marshal and disseminate the available evidence may also play a part. For surgeons, decisions taken in an individual capacity are their own and their responsibility. Their choice is based on many factors, including the conditioning resulting from early education, what has been learnt from mentors and what is recommended by the guidelines, whether local or national. Guidelines are not prescriptive and, surprisingly, many on the same subject may vary considerably from country to country and even within a country from one scientific society to another [1]. This could be an explanation for diversity in the choice of treatment, when this occurs. This issue of Colorectal Disease contains an interesting paper [2] in which a survey amongst rectal surgeons has shown a wide variation in decision-taking in advising a diverting stoma after a colorectal anastomosis. One of the reasons for this could be related to the unquantifiable willingness of the more experienced surgeons to ‘take a chance’ and avoid a stoma to a greater
degree than others. One could argue that such differences in attitude are a feature of human nature and a reflection of individual variation. Only if solid evidence is available can this factor be diminished, and when it is the patient’s best interest lies in following it. Indeed in the presence of clear-cut evidence all other alternatives would be unacceptable. There is still a long way to go before the variance in practice based on non-objective factors gives way to evidence, and it may be many years before the application of scientific progress is fully incorporated into daily practice. Thus, although the scientific evidence for the protective value of a defunctioning stoma is well established [3] there is still a difference in opinion on when it should be performed. Of course every study leading to increase in the body of scientific evidence should be questioned scientifically according to methodological criteria, but several instruments now exist to evaluate the quality and level of evidence: examples include the Levels of Evidence table from the Oxford Centre for Evidence Based Medicine, the Newcastle Ottawa score and the Jadad score. The most important reasons for not doing the same thing are still the lack of Grade 1 evidence and individual interpretation of existing evidence.
Peer Wille-Jørgensen Digestive Disease Center, Bispebjerg Hospital, Copenhagen, Denmark
References 1 Augestad K, Lindsetmo R-O, Stulberg J et al. International Preoperative Rectal Cancer Management: staging, neoadjuvant treatment, and impact of multidisciplinary teams. World J Surg 2010; 34: 2689–700. 2 MacDermid E, Young CJ, Young J, Solomon M. Descision-making in rectal cancer surgery. Colorectal Dis 2014; 16: 203–8. 3 Matthiesen P, Hallbo O, Rutegard J, Dahl RSJ. Population-based study of risk factors for postoperative death after anterior resection of the rectum. Br J Surg 2006; 93: 498– 503.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 155
155
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
