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Don’t Be the Last…

Panchbhavi, Vinod K. MD, FACS

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Techniques in Foot & Ankle Surgery: December 2014 - Volume 13 - Issue 4 - p 175
doi: 10.1097/BTF.0000000000000064
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…And don’t be the first, when it comes to adopting new technology—a wise cautionary mantra to live by. Whether it is new software or a new device, version “1” that has just come out is followed by a better one after the “bugs” are worked out. We see this happen with new things we come across in our day-to-day life and also with implants that hit the market for use in our medical practices. Most of the “bugs” with preexisting designs and those that can be painstakingly predicted or sought for in laboratory or pretrial experiments are addressed when it comes to making the new or newer versions better in everything, from being user friendly to outcome friendly. Nevertheless, in our pursuit for excellence, and there always being room for improvement, we can rest assured that there will always be something “newer and better.”

But is “newer” always “better”? We rely on randomized, controlled clinical trials to help us decide whether the new idea or new method is better than existing ones. But is one such trial enough? Does it need to be repeated? Should it be repeated at another center? If so, how many times should it be repeated before the evidence becomes compelling or widely accepted? In most scenarios, however, the evidence builds as a scientific pyramid over time, by case reports, by case series, and finally crowned by randomized, controlled clinical trials considered the gold standard of scientific research. This helps us practice what we call “evidence-based medicine.”

Even prospective randomized controlled trials, however, have limitations, and at times it is difficult to hang our hats on what comes out, despite the effort. In addition, there are many management decisions in which the luxury of sound evidence, based on the aforementioned scientific pyramid, is not available. This is when we rely on experience based on case reports, anecdotes, and the experience of others considered experts or key opinion leaders. In other words, in such situations we practice what has been termed “eminence-based medicine.”

Often, therefore, our medical decision making not only is based on our knowledge of current literature but also is tempered with wisdom gained with training and by experience, a practice that lies somewhere between “evidence-based medicine” and “eminence-based medicine.” And when it comes to adopting something new for practice en masse, we should again be in between, and here, it is not rushing to be the first and not remaining last.

Vinod K. Panchbhavi, MD, FACS

© 2014 by Lippincott Williams & Wilkins