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Can we do any better?
Editorial
Can We Do Any Better?
This issue includes an article that I believe will have profound impact on the practice of medicine in the future. It is the paper by Jobe et al on the failure of traditional probability statistics to deal with the types of decisions clinicians face daily. How many of us have found that the patient sitting in our office does not fit the randomized study—and what do you do? Consider a patient who has mild diabetes, moderate hypertension, familial hypertriglyceridemia, and TIAs; 4-vessel digital subtraction angiography reveals a 50% right carotid stenosis. Is this patient covered by any published randomized study? The answer is no. Randomized studies are simplified to allow an all-or-none decision— e.g., carotid stenosis more or less than 70%, diagnosed by 2-vessel angiogram. Other factors are believed to be neutralized by the random selection. Unfortunately, this simplification means that the randomized studies that have already been done, even if they are not flawed by poor study design or other faults, are flawed by the logic used in reaching their conclusions. Fuzzy logic, in contrast, will allow us to include all the contributing factors in an individual case—as we do in our clinical practices. Clinicians are also being asked to use “evidencebased medicine” in choosing the appropriate treatments for their patients. What is this evidencebased medicine based on? Probability statistics. Now what happens? I believe we are in for some interesting times as clinical scientists deal with the controversy of probability versus fuzzy logic. The key question in this debate—the only one that counts—is “can we do it better?” The article by Roberti et al on the results of an aggressive surgical approach to posterior fossa skull base tumors raises another question about our future as neurosurgeons. The authors are accomplished surgeons experienced in using skull base approaches to reach these tumors. However, can any surgeon justify a 41 to 89% permanent morbidity rate? Cranial nerve deficits were found in
0090-3019/01/$–see front matter PII S0090-3019(01)00508-0
47% of their patients postoperatively; facial weakness and hearing loss in 20%. Can we do it better? Roberti et al. have shown us what can be done using this aggressive approach, but what about radiosurgery and limited surgery? What about targeted chemotherapy on surface receptors or messenger systems, which has recently been successfully used for leukemia? Are these treatments better? And can a surgeon know the results of his approach before doing 110 cases of petroclival meningiomas? The surgeon should ask, after each operation, “how could I have done it better?” Perhaps it would not take 110 cases to answer that question. Roberti et al have provided us with a very detailed analysis of their work—this alone is credible. But can we do it better? Also in this issue, Ross and Guzman report on their early experience in performing carotid endarterectomy. The commentators to this article question whether the morbidity rates reported by the authors are too high. Yet the authors conclude that “less experienced individuals can perform this procedure with good results.” How would the 4 to 7% of patients with stroke/morbidity feel about this conclusion? Can we do better? Patients and referring doctors will not be satisfied with a surgeon who can only offer treatments with high morbidity rates; they can and will shop for the best options. Can we do it better? This deserves honest discussion among all neurosurgeons. Perhaps it would be a good topic for discussion at a main session of a national meeting, with representatives from insurance companies, the general public, and other “users” of the system. There is a way— but are we up to it, as individuals or as a society? If you were the patient, how would you want the question to be answered? James I. Ausman, M.D., Ph.D Editor
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Can We Do Any Better?
This issue includes an article that I believe will have profound impact on the practice of medicine in the future. It is the paper by Jobe et al on the failure of traditional probability statistics to deal with the types of decisions clinicians face daily. How many of us have found that the patient sitting in our office does not fit the randomized study—and what do you do? Consider a patient who has mild diabetes, moderate hypertension, familial hypertriglyceridemia, and TIAs; 4-vessel digital subtraction angiography reveals a 50% right carotid stenosis. Is this patient covered by any published randomized study? The answer is no. Randomized studies are simplified to allow an all-or-none decision— e.g., carotid stenosis more or less than 70%, diagnosed by 2-vessel angiogram. Other factors are believed to be neutralized by the random selection. Unfortunately, this simplification means that the randomized studies that have already been done, even if they are not flawed by poor study design or other faults, are flawed by the logic used in reaching their conclusions. Fuzzy logic, in contrast, will allow us to include all the contributing factors in an individual case—as we do in our clinical practices. Clinicians are also being asked to use “evidencebased medicine” in choosing the appropriate treatments for their patients. What is this evidencebased medicine based on? Probability statistics. Now what happens? I believe we are in for some interesting times as clinical scientists deal with the controversy of probability versus fuzzy logic. The key question in this debate—the only one that counts—is “can we do it better?” The article by Roberti et al on the results of an aggressive surgical approach to posterior fossa skull base tumors raises another question about our future as neurosurgeons. The authors are accomplished surgeons experienced in using skull base approaches to reach these tumors. However, can any surgeon justify a 41 to 89% permanent morbidity rate? Cranial nerve deficits were found in
0090-3019/01/$–see front matter PII S0090-3019(01)00508-0
47% of their patients postoperatively; facial weakness and hearing loss in 20%. Can we do it better? Roberti et al. have shown us what can be done using this aggressive approach, but what about radiosurgery and limited surgery? What about targeted chemotherapy on surface receptors or messenger systems, which has recently been successfully used for leukemia? Are these treatments better? And can a surgeon know the results of his approach before doing 110 cases of petroclival meningiomas? The surgeon should ask, after each operation, “how could I have done it better?” Perhaps it would not take 110 cases to answer that question. Roberti et al have provided us with a very detailed analysis of their work—this alone is credible. But can we do it better? Also in this issue, Ross and Guzman report on their early experience in performing carotid endarterectomy. The commentators to this article question whether the morbidity rates reported by the authors are too high. Yet the authors conclude that “less experienced individuals can perform this procedure with good results.” How would the 4 to 7% of patients with stroke/morbidity feel about this conclusion? Can we do better? Patients and referring doctors will not be satisfied with a surgeon who can only offer treatments with high morbidity rates; they can and will shop for the best options. Can we do it better? This deserves honest discussion among all neurosurgeons. Perhaps it would be a good topic for discussion at a main session of a national meeting, with representatives from insurance companies, the general public, and other “users” of the system. There is a way— but are we up to it, as individuals or as a society? If you were the patient, how would you want the question to be answered? James I. Ausman, M.D., Ph.D Editor
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010