The Ascent of Evidence-Based Medicine

For plastic and reconstructive surgeons who rely on Medicare and government-centric payment systems, welcome to the brave new world of evidence-based medicine (EBM). You are not alone. A large majority of physicians and related practitioners have already or will be touched in some way by EBM.

As it relates to plastic surgery, EBM is discussed in considerable detail in articles available free at the American Society of Plastic Surgeons (ASPS) Web site.

For example, a good overview of the history and application of evidence-based medicine can be found at this site: journals.www.com/plasreconsurg/pages/collectiondetails.aspx?TopicalCollectionId=24. Around a dozen free research and editorial articles are housed on the site, with charts and tables, all clearly written.

EBM has been described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” That quote belongs to a recent article titled, “Evidence Based Medicine: What It Is and What It Isn’t.” (www.ncbi.nlm.nih.gov/pmc/articles/PMC2349778/pdf/bmj00524-0009.pdf)

EBM is the integration of physicians’ clinical expertise with the best available external clinical evidence from systematic research. “By individual clinical expertise,” the authors continue, “we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.”

The same article articulated some of the criticisms of EBM, including claims it has been set up as a cost-cutting tool for government agencies and insurers; and to suppress clinical freedom.

Critics of EBM offer less compelling arguments, but their viewpoint should be examined and not dismissed.

The reality of EBM, though, is that over time its implementation has sparked improvements in clinical research and, if empirical data can be trusted, overall improvements in surgery outcomes.

It is clear that the people who have and continue to contribute to the development of plastic surgery—namely, all who are reading this editorial and then some—are steeped in EBM via training, mentoring, and practical experience. Therefore, plastic surgeons have contributed strongly to concepts and practices espoused in EBM.

Interestingly, the American Society for Aesthetic Plastic Surgery (ASAPS) earlier this year made note of EBM in its predictions for cosmetic surgery in 2011. The surveyed group includes leading plastic surgeons in the United States who are involved in cutting-edge aesthetic technology.

In its statement, the Society wrote, “Following the trend in increased consumer sophistication, patients will increasingly want to know if the latest procedure and device being touted on the Internet and TV talk show really works and if it is safe. By incorporating evidence-based medicine into the core specialties of plastic surgery, the Aesthetic Society will make it easier for both doctors and patients to determine fact from fiction.”

Physicians who have adopted EBM now probably know what it means to observe a paradigm shift—in this case, to survive a sea change in how clinical research is conducted throughout the health care universe.

There are compelling reasons for adopting the principles of EBM, and there are financial incentives (via government programs) for physicians and organizations, as well. Recent buzz among practitioners flared up when the government starting to pay bonuses to physicians and organizations that have adopted EBM.

The use of EBM in the aesthetic medicine predates the government-mandated empirical guidelines. The next generation of plastic surgeons will be more thoroughly aware of its concepts and principles earlier on in their training.

Some controversy centers on mandates, including the demand for guidelines that place reporting standards on clinical research and how that integrates within your practice.

In time, these systemic bugs can get worked out, if people are willing to work on it.

The empirical guidelines do not apply equally across all treatments and disciplines. Researchers concede that “one implementation model does not fit all and that, instead, a series of overlapping implementation strategies best target specific groups.”
(www.ncbi.nlm.nih.gov/pubmed/11583124?dopt=Abstract)

The guidelines affect a wide range of health care providers, including physicians, surgeons, nurses, pharmacists, equipment suppliers, administrators, and patients.