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Is There More to Life Than an Evidence-based Study

Jupiter, Jesse B., MD

Techniques in Hand & Upper Extremity Surgery: March 2019 - Volume 23 - Issue 1 - p 1
doi: 10.1097/BTH.0000000000000238

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Conflicts of Interest and Source of Funding: The author reports no conflicts of interest and no source of funding.

Address correspondence and reprint requests to Jesse B. Jupiter, MD, Suite 2100, Yawkey Bldg, Massachusetts General Hospital, 55 Parkman, St. Boston 02114, Massachusetts. E-mail:

Have you ever questioned why one of your “best studies” was rejected from publication? I suspect many of us have! While the majority of surgical journals follow a well-established editorial process and seek to cover a wide breadth of material, a well-designed study acceptable to both reviewers and editors sometimes seems harder and harder to achieve.

We exist in the era of evidence-based medicine (EBM), but is this the be all and end all of clinical studies? A number of misconceptions remain regarding EBM. The first is that EBM ignores clinical expertise, as even excellent external evidence may be inapplicable or inappropriate for an individual patient. The second misconception is that EBM is not possible without a randomized controlled trial. Observational studies can, in fact, generate highly significant hypotheses and set the stage for further experimental work. Thirdly, the feeling that EBM is all about statistics and numbers yet a significant “P” value may unduly influence interpretation. Overall, EBM is no doubt a basis for good and economic health care, but we also need scientific development, which may require a balance between creativity and discipline.

Likewise, there are a number of definable flaws in cohort, observational studies, which will lead to an unfavorable review. Among these include whether or not clear and correct questions are asked; how the study itself was set up; well-defined inclusion criteria; appropriate measurements used; how the data are analyzed; and/or how the results are presented.

With randomized controlled trials, the study must strive to eliminate bias. Bias may arise from dissimilar baseline groups, referred to as susceptibility bias. Performance bias will exist from differing skill levels in performing the procedure as well as different frequency of follow-up visits. Detection bias reflects outcomes measured incomparably and may be limited by double blinding. Lastly, transfer bias reflects a differential loss to follow-up between groups.

We believe the Journal of Techniques in Hand and Upper Extremity will continuously serve a role in providing a platform for clinicians to offer unique ideas and techniques that are presented clearly with adequate outcome experience and recognition of real or potential complications.

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