12/08/2022
Diminishing returns? A big part of recommending surgical and medical interventions lies in an honest calculation of risk/benefit ratios. Evidence-based studies are the correct way to gather the data required to make those analysis. Unfortunately, there are situations where we do not yet have the correct data to provide a proper risk/benefit analysis. While evidence-based medicine studies utilize statistics on pools of patients, they cannot specifically predict anything for a particular individual patient. Some pieces of information may be unavailable or not easily comparable numerically. For example, different surgeons may have different personal outcomes, and even individual surgeons may have different outcomes in different settings. A patient has innumerable idiosyncrasies, from genetic factors, to environmental, to presentation at different moments of evolution of a disease process. Of course, it is a stated goal of modern medicine to study, gather and analyze as much data as possible on patient outcomes with different therapeutic modalities and to constantly shrink the information gap. But a future goal does not answer all the questions we may have for the patient we see tomorrow in our office or hospital. Ultimately, it is part of our responsibility as physicians to give our best opinion and recommendations even despite all the uncertainties that we may face. This is where training, experience and observational skills combine into medical intuition that allows us to recommend a best course of action. When you see the photo above, what do you actually see? How does your brain process that image? As a surgeon, I immediately start looking at three-dimensional dissection planes. How would I approach it? Will it improve vision? What caveats will I encounter? Is it worth attempting it? All these thoughts are immediate, non-verbal, and intuitive, like Gladwell described in his book Blink. I am not arguing against evidence-based medicine. Instead, I am advocating for all doctors to engage on a deliberate process of professional improvement, to develop that intuitive medical impression, and fill the inherent gaps of modern medicine.