Layton F. “Bing” Rikkers, MD, FACS

In his most recent bestseller, Being Mortal, Dr. Atul Gawande has again raised social awareness of the inadequacies of our health care system in assisting patients with end-of-life decisions and care. In his treatise, he laments his own lack of training in medical school and residency regarding what he has emphasized should be a key component of any physician’s education.

To some degree, there has been a greater emphasis on palliative care training in our medical schools since Dr. Gawande graduated two decades or so ago. The subject of physician-patient communication, including those difficult discussions that should occur near the end of life, is now incorporated into most medical school curricula. Additionally, palliative care has become a respected and growing subspecialty within both medicine and surgery.* Despite these improvements, still far too many patients die while receiving futile end-of-life care in our nation’s intensive care units and hospital wards rather than in the comfort of their homes surrounded by loved ones. Although referrals have increased, too few patients are afforded the opportunity to utilize hospice care and, those that do, are often referred too late in the course of their terminal disease to obtain full benefit

Why are we not doing better? Two likely contributors include a physician mindset that only cure is success and death represents failure, and unrealistic expectations of patients as to what modern medicine can accomplish. A more fixable and probably more important factor is the failure of doctors to effectively communicate during these highly stressful circumstances. As emphasized by Gawande and from my own experience, the key to negotiating a sensible path in hopeless, end-of-life situations is frequent, reasonable, and realistic consultation with our patients.

Not only are the conversations usually difficult and demanding, but the choices of whether to pursue treatment or remove life-sustaining efforts are frequently not well-defined. While these challenging clinical scenarios are often painted as black and white in the lay press, any physician or surgeon who has cared for such patients realizes that there is a delicate and precarious balance between providing hope, administering appropriate aggressive treatment, and ensuring patient comfort. In a well-intentioned attempt to leave some remnant of hope, we physicians too frequently paint an unrealistic picture for our patients.

Advance patient directives have been promoted as one means for patients to avoid futile, uncomfortable, and unnecessary care during the last stage of their lives. Though I by no means wish to discourage these often useful legal documents, they should not be entered into naively. For example, aggressive life-sustaining care for a patient with extensive metastatic lung cancer is likely inappropriate. On the other hand, short-term ventilator assistance for an elderly unconscious person recovering from an automobile accident may result in many additional years of enjoyable and productive life. Patients need to understand that all grave clinical situations are not equal and that their advance directives should be flexible enough to cover a variety of circumstances.

It has been well established that most patients and families have selective hearing and understanding. Even when the details of a major operation with a greater likelihood of a negative rather than a positive outcome are carefully and clearly presented using lay language, the potential positive outcomes frequently push the more probable adverse consequences into hidden recesses of the brain. In my experience, the more desperate the situation, the more often it is that the possibility of an unsuccessful outcome will be masked or denied by patients or their family members. Even though in my practice I carefully explained the high probability of eventual recurrence when operating on patients with pancreatic cancer, many of them were surprised and some were even quite indignant when this disappointing consequence developed. In my opinion, the most effective means to avoid such misunderstandings is to always have the patient and/or family relate their comprehension of the just-completed conversation. It is then essential to re-emphasize the important details that they suppressed and pushed to the background from your initial explanation.

In these challenging end-of-life moments, what advice should we offer? One question that should almost never be asked of the patient or his/her representative is: “Would you like everything possible done?” Especially for a family member who may take on considerable guilt by answering in the negative, the response will nearly always be “yes” no matter how unlikely a successful outcome. Rather, I believe that recommending only reasonable options, including and possibly emphasizing the choice of comfort therapy alone despite the certainty of death, is our obligation. We should be cognizant of the fact that the decision made by the patient is often highly dependent on how the alternatives are presented by his/her doctor. After clearly presenting the therapeutic options and their likely consequences, it may be helpful to relate what you would do yourself for a loved one in the same circumstances.

As in many other aspects of our lives, a useful guidepost in these situations is the Golden Rule: “Do unto others as you would have done unto yourself.” Interestingly, most probably based on our intimate exposure to numerous unnecessarily complicated and uncomfortable deaths, there is evidence that we physicians choose to die differently than our patients. In a recent essay, Dr. Ken Murray presented data from the John Hopkins Precursors Study that suggested doctors are less likely than their patients to submit themselves to futile end-of-life care. (Murray K: Doctors really do die differently. Zocalopublicsquare.org; accessed March 29, 2015). The proof he presents is from a survey of graduates of Johns Hopkins School of Medicine between 1948 and 1964. It revealed that 65% of them had written their own advance directives in comparison to 20% for the public at large. In addition, only 10% of the graduates would opt for cardiopulmonary resuscitation if they were comatose, compared with 75% of the general population.

I suspect that most surgeons, desiring a dignified death for themselves, are not surprised by these statistics. Therefore, we owe it to our patients to be as compassionate and thoughtful in managing the last stage of their lives as we have traditionally been trained to do in earlier phases when cure was a realistic expectation.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

*Recognizing the importance of end-of-life issues in a surgeon’s education, in 2012 ACS Surgery News initiated a series of articles on various aspects of palliative care.

In his most recent bestseller, Being Mortal, Dr. Atul Gawande has again raised social awareness of the inadequacies of our health care system in assisting patients with end-of-life decisions and care. In his treatise, he laments his own lack of training in medical school and residency regarding what he has emphasized should be a key component of any physician’s education.

To some degree, there has been a greater emphasis on palliative care training in our medical schools since Dr. Gawande graduated two decades or so ago. The subject of physician-patient communication, including those difficult discussions that should occur near the end of life, is now incorporated into most medical school curricula. Additionally, palliative care has become a respected and growing subspecialty within both medicine and surgery.* Despite these improvements, still far too many patients die while receiving futile end-of-life care in our nation’s intensive care units and hospital wards rather than in the comfort of their homes surrounded by loved ones. Although referrals have increased, too few patients are afforded the opportunity to utilize hospice care and, those that do, are often referred too late in the course of their terminal disease to obtain full benefit

Why are we not doing better? Two likely contributors include a physician mindset that only cure is success and death represents failure, and unrealistic expectations of patients as to what modern medicine can accomplish. A more fixable and probably more important factor is the failure of doctors to effectively communicate during these highly stressful circumstances. As emphasized by Gawande and from my own experience, the key to negotiating a sensible path in hopeless, end-of-life situations is frequent, reasonable, and realistic consultation with our patients.

Not only are the conversations usually difficult and demanding, but the choices of whether to pursue treatment or remove life-sustaining efforts are frequently not well-defined. While these challenging clinical scenarios are often painted as black and white in the lay press, any physician or surgeon who has cared for such patients realizes that there is a delicate and precarious balance between providing hope, administering appropriate aggressive treatment, and ensuring patient comfort. In a well-intentioned attempt to leave some remnant of hope, we physicians too frequently paint an unrealistic picture for our patients.

Advance patient directives have been promoted as one means for patients to avoid futile, uncomfortable, and unnecessary care during the last stage of their lives. Though I by no means wish to discourage these often useful legal documents, they should not be entered into naively. For example, aggressive life-sustaining care for a patient with extensive metastatic lung cancer is likely inappropriate. On the other hand, short-term ventilator assistance for an elderly unconscious person recovering from an automobile accident may result in many additional years of enjoyable and productive life. Patients need to understand that all grave clinical situations are not equal and that their advance directives should be flexible enough to cover a variety of circumstances.

It has been well established that most patients and families have selective hearing and understanding. Even when the details of a major operation with a greater likelihood of a negative rather than a positive outcome are carefully and clearly presented using lay language, the potential positive outcomes frequently push the more probable adverse consequences into hidden recesses of the brain. In my experience, the more desperate the situation, the more often it is that the possibility of an unsuccessful outcome will be masked or denied by patients or their family members. Even though in my practice I carefully explained the high probability of eventual recurrence when operating on patients with pancreatic cancer, many of them were surprised and some were even quite indignant when this disappointing consequence developed. In my opinion, the most effective means to avoid such misunderstandings is to always have the patient and/or family relate their comprehension of the just-completed conversation. It is then essential to re-emphasize the important details that they suppressed and pushed to the background from your initial explanation.

In these challenging end-of-life moments, what advice should we offer? One question that should almost never be asked of the patient or his/her representative is: “Would you like everything possible done?” Especially for a family member who may take on considerable guilt by answering in the negative, the response will nearly always be “yes” no matter how unlikely a successful outcome. Rather, I believe that recommending only reasonable options, including and possibly emphasizing the choice of comfort therapy alone despite the certainty of death, is our obligation. We should be cognizant of the fact that the decision made by the patient is often highly dependent on how the alternatives are presented by his/her doctor. After clearly presenting the therapeutic options and their likely consequences, it may be helpful to relate what you would do yourself for a loved one in the same circumstances.

As in many other aspects of our lives, a useful guidepost in these situations is the Golden Rule: “Do unto others as you would have done unto yourself.” Interestingly, most probably based on our intimate exposure to numerous unnecessarily complicated and uncomfortable deaths, there is evidence that we physicians choose to die differently than our patients. In a recent essay, Dr. Ken Murray presented data from the John Hopkins Precursors Study that suggested doctors are less likely than their patients to submit themselves to futile end-of-life care. (Murray K: Doctors really do die differently. Zocalopublicsquare.org; accessed March 29, 2015). The proof he presents is from a survey of graduates of Johns Hopkins School of Medicine between 1948 and 1964. It revealed that 65% of them had written their own advance directives in comparison to 20% for the public at large. In addition, only 10% of the graduates would opt for cardiopulmonary resuscitation if they were comatose, compared with 75% of the general population.

I suspect that most surgeons, desiring a dignified death for themselves, are not surprised by these statistics. Therefore, we owe it to our patients to be as compassionate and thoughtful in managing the last stage of their lives as we have traditionally been trained to do in earlier phases when cure was a realistic expectation.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

*Recognizing the importance of end-of-life issues in a surgeon’s education, in 2012 ACS Surgery News initiated a series of articles on various aspects of palliative care.

In his most recent bestseller, Being Mortal, Dr. Atul Gawande has again raised social awareness of the inadequacies of our health care system in assisting patients with end-of-life decisions and care. In his treatise, he laments his own lack of training in medical school and residency regarding what he has emphasized should be a key component of any physician’s education.

To some degree, there has been a greater emphasis on palliative care training in our medical schools since Dr. Gawande graduated two decades or so ago. The subject of physician-patient communication, including those difficult discussions that should occur near the end of life, is now incorporated into most medical school curricula. Additionally, palliative care has become a respected and growing subspecialty within both medicine and surgery.* Despite these improvements, still far too many patients die while receiving futile end-of-life care in our nation’s intensive care units and hospital wards rather than in the comfort of their homes surrounded by loved ones. Although referrals have increased, too few patients are afforded the opportunity to utilize hospice care and, those that do, are often referred too late in the course of their terminal disease to obtain full benefit

Why are we not doing better? Two likely contributors include a physician mindset that only cure is success and death represents failure, and unrealistic expectations of patients as to what modern medicine can accomplish. A more fixable and probably more important factor is the failure of doctors to effectively communicate during these highly stressful circumstances. As emphasized by Gawande and from my own experience, the key to negotiating a sensible path in hopeless, end-of-life situations is frequent, reasonable, and realistic consultation with our patients.

Not only are the conversations usually difficult and demanding, but the choices of whether to pursue treatment or remove life-sustaining efforts are frequently not well-defined. While these challenging clinical scenarios are often painted as black and white in the lay press, any physician or surgeon who has cared for such patients realizes that there is a delicate and precarious balance between providing hope, administering appropriate aggressive treatment, and ensuring patient comfort. In a well-intentioned attempt to leave some remnant of hope, we physicians too frequently paint an unrealistic picture for our patients.

Advance patient directives have been promoted as one means for patients to avoid futile, uncomfortable, and unnecessary care during the last stage of their lives. Though I by no means wish to discourage these often useful legal documents, they should not be entered into naively. For example, aggressive life-sustaining care for a patient with extensive metastatic lung cancer is likely inappropriate. On the other hand, short-term ventilator assistance for an elderly unconscious person recovering from an automobile accident may result in many additional years of enjoyable and productive life. Patients need to understand that all grave clinical situations are not equal and that their advance directives should be flexible enough to cover a variety of circumstances.

It has been well established that most patients and families have selective hearing and understanding. Even when the details of a major operation with a greater likelihood of a negative rather than a positive outcome are carefully and clearly presented using lay language, the potential positive outcomes frequently push the more probable adverse consequences into hidden recesses of the brain. In my experience, the more desperate the situation, the more often it is that the possibility of an unsuccessful outcome will be masked or denied by patients or their family members. Even though in my practice I carefully explained the high probability of eventual recurrence when operating on patients with pancreatic cancer, many of them were surprised and some were even quite indignant when this disappointing consequence developed. In my opinion, the most effective means to avoid such misunderstandings is to always have the patient and/or family relate their comprehension of the just-completed conversation. It is then essential to re-emphasize the important details that they suppressed and pushed to the background from your initial explanation.

In these challenging end-of-life moments, what advice should we offer? One question that should almost never be asked of the patient or his/her representative is: “Would you like everything possible done?” Especially for a family member who may take on considerable guilt by answering in the negative, the response will nearly always be “yes” no matter how unlikely a successful outcome. Rather, I believe that recommending only reasonable options, including and possibly emphasizing the choice of comfort therapy alone despite the certainty of death, is our obligation. We should be cognizant of the fact that the decision made by the patient is often highly dependent on how the alternatives are presented by his/her doctor. After clearly presenting the therapeutic options and their likely consequences, it may be helpful to relate what you would do yourself for a loved one in the same circumstances.

As in many other aspects of our lives, a useful guidepost in these situations is the Golden Rule: “Do unto others as you would have done unto yourself.” Interestingly, most probably based on our intimate exposure to numerous unnecessarily complicated and uncomfortable deaths, there is evidence that we physicians choose to die differently than our patients. In a recent essay, Dr. Ken Murray presented data from the John Hopkins Precursors Study that suggested doctors are less likely than their patients to submit themselves to futile end-of-life care. (Murray K: Doctors really do die differently. Zocalopublicsquare.org; accessed March 29, 2015). The proof he presents is from a survey of graduates of Johns Hopkins School of Medicine between 1948 and 1964. It revealed that 65% of them had written their own advance directives in comparison to 20% for the public at large. In addition, only 10% of the graduates would opt for cardiopulmonary resuscitation if they were comatose, compared with 75% of the general population.

I suspect that most surgeons, desiring a dignified death for themselves, are not surprised by these statistics. Therefore, we owe it to our patients to be as compassionate and thoughtful in managing the last stage of their lives as we have traditionally been trained to do in earlier phases when cure was a realistic expectation.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

*Recognizing the importance of end-of-life issues in a surgeon’s education, in 2012 ACS Surgery News initiated a series of articles on various aspects of palliative care.

Ever since the earliest medical practitioners treated the first patients, a tension has existed between potentially beneficial innovation and unintentional harm. For many centuries doctors relied on their own experience or intuition to determine what was best for those whom they treated. It was not until the 17th century that Francis Bacon introduced the scientific method that consisted of systematic observation and testing of hypotheses. In the case of clinical science, this provided an objective means of determining which treatments would be in the best interest of patients. Since then, society has greatly benefited from remarkable medical advancements based on what is essentially human experimentation, much of it noble, but unfortunately some episodes quite tragic, misguided, and even demonic.

The most notorious human research abuses were those perpetrated by the Nazi regime during the Holocaust. There were only 200 survivors from the 1,500 sets of twins forced to participate in Josef Mengele’s infamous twin experiments at the Auschwitz concentration camp. Many of these investigations were genetic experiments intended to prove the superiority of the Aryan race. Little useful scientific information was gained from these inhumane and evil studies.

However, totalitarianism is not a prerequisite for mistreatment of human subjects. The American research community has its own checkered past. Possibly the most well-known abuse is the Tuskegee syphilis experiments that were conducted between 1932 and 1972 by the U.S. Public Health Service. Four hundred impoverished African American males infected with syphilis, who were not fully informed about their disease, were closely followed in order to record the natural history of this deadly and debilitating illness. These patients were not treated with penicillin although the drug became available in 1947. As a result, over one-third of the subjects died of their disease, many of their wives contracted syphilis, and numerous children were unnecessarily born with congenital syphilis.

On the other end of the ethical scale are a number of noble researchers scattered throughout history who insisted on experimenting on themselves before submitting others to their treatments or procedures. A prime example is a courageous and creative German surgical intern, Werner Forssmann, who paved the path to heart surgery through self-experimentation. Even into the 20th century, it was taboo for a physician to touch the living heart. Thus, much of its physiology and pathophysiology remained shrouded in mystery. In 1929, Dr. Forssmann did a cut-down on his antecubital vein, inserted a ureteral catheter into the right side of his heart, and then descended a flight of stairs to confirm its position by x-ray. Later experiments, also performed on him, resulted in the first cardiac angiograms. Although heavily criticized by his superiors and the German medical establishment, Dr. Forssmann, an obscure urologist and general surgeon at the time, was eventually rewarded by sharing the Nobel Prize in 1956.

From the very beginning of surgery as a clinical science, surgeons have sat on the precipice of beneficial innovation versus unintentional harm to their patients. Because of the very nature of what they do, it has not usually been possible for them to self-experiment before testing their ideas on others. Every operation ever devised, occasionally with, but often without, animal experimentation, has had its initial human guinea pigs. In fact, surgeons have generally been given freer rein to try new and untested procedures or to modify older accepted ones. They have had greater license than have their counterparts who innovate with drugs and medical devices and are thus more tightly regulated by agencies such as the Food and Drug Administration.

In the best of circumstances, surgical patients are fully informed as to the potential consequences of a novel operation, both good and bad, and the results are carefully recorded to determine the benefit/harm ratio of the procedure. Ideally, though it is often not possible, the new approach is compared to a proven alternative therapy in a carefully designed trial. Unfortunately, such careful analysis has not always been done.

A glaring example of surgical human experimentation gone wrong is the frontal lobotomy story. In the early part of the 20th century, mental institutions in this country and throughout the world were filled with desperate patients for whom there were few therapeutic alternatives available. Many of these patients were incapable of giving meaningful informed consent. In 1935, frontal lobotomy was introduced by Antonio Moniz, a Portuguese neurologist, who later shared in a highly controversial Nobel Prize for his discovery. In 1946, an American neuropsychiatrist, Walter Freeman, modified the procedure so it could be done by psychiatrists with an ice pick–like instrument via a transorbital approach. A neurosurgeon performing a craniotomy, general anesthesia, and an operating room were no longer necessary, resulting in the rapid proliferation of this simpler operation despite its increasingly well-known and devastating side effects of loss of personality, decreased cognition, and even death. Only after more than 40,000 procedures were done in the United States did mounting criticism eventually lead to a ban on most lobotomies..

On the more noble side of surgical innovation, if Dr. Thomas Starzl and Dr. C. Walton Lillehei had not persisted despite failure after failure and death after death, liver transplantation and cardiac surgery would not have evolved to the lifesaving therapies they are today. These surgical pioneers and many others like them, who have persisted in the face of failure to develop new and useful approaches to surgical disease, can hardly be condemned for their human experiments that were disasters in the short term but enduring medical advancements in the long-term. Their initial patients were courageous, desperate, and hopefully well informed.

What separates these successful forerunners from those who promoted the lobotomy debacle? One factor may be history itself. Passed by Congress in response to the atrocities that had occurred earlier in the century, the National Research Act of 1974 mandated Institutional Review Boards (IRBs) in institutions conducting human research. Although the initial attempts at operating on the heart and transplanting the liver predated IRBs, much of the development of these specialties as we know them today took place under the watchful eye of these committees.

Whereas Freeman’s modifications made lobotomy a procedure that could be performed by almost anyone, cardiac surgery and liver transplantation required resources that could be provided only by major academic institutions.

While lobotomy almost became a traveling sideshow with poor documentation of results, the earliest attempts at heart surgery and liver transplantation were carefully recorded in the surgical literature for the entire academic community to analyze and ponder.

We owe much to those surgeons who persisted against great odds to develop our craft and to those patients with the courage to be a part of the great enterprise of surgical innovation. Without their daring, perseverance, and creativity, surgery would not have evolved to the diverse and noble specialty it is today. It is now incumbent upon us to make certain that future surgical innovation transpires only under an umbrella of safe, well-informed, and satisfactorily documented and controlled human experimentation.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

Ever since the earliest medical practitioners treated the first patients, a tension has existed between potentially beneficial innovation and unintentional harm. For many centuries doctors relied on their own experience or intuition to determine what was best for those whom they treated. It was not until the 17th century that Francis Bacon introduced the scientific method that consisted of systematic observation and testing of hypotheses. In the case of clinical science, this provided an objective means of determining which treatments would be in the best interest of patients. Since then, society has greatly benefited from remarkable medical advancements based on what is essentially human experimentation, much of it noble, but unfortunately some episodes quite tragic, misguided, and even demonic.

The most notorious human research abuses were those perpetrated by the Nazi regime during the Holocaust. There were only 200 survivors from the 1,500 sets of twins forced to participate in Josef Mengele’s infamous twin experiments at the Auschwitz concentration camp. Many of these investigations were genetic experiments intended to prove the superiority of the Aryan race. Little useful scientific information was gained from these inhumane and evil studies.

However, totalitarianism is not a prerequisite for mistreatment of human subjects. The American research community has its own checkered past. Possibly the most well-known abuse is the Tuskegee syphilis experiments that were conducted between 1932 and 1972 by the U.S. Public Health Service. Four hundred impoverished African American males infected with syphilis, who were not fully informed about their disease, were closely followed in order to record the natural history of this deadly and debilitating illness. These patients were not treated with penicillin although the drug became available in 1947. As a result, over one-third of the subjects died of their disease, many of their wives contracted syphilis, and numerous children were unnecessarily born with congenital syphilis.

On the other end of the ethical scale are a number of noble researchers scattered throughout history who insisted on experimenting on themselves before submitting others to their treatments or procedures. A prime example is a courageous and creative German surgical intern, Werner Forssmann, who paved the path to heart surgery through self-experimentation. Even into the 20th century, it was taboo for a physician to touch the living heart. Thus, much of its physiology and pathophysiology remained shrouded in mystery. In 1929, Dr. Forssmann did a cut-down on his antecubital vein, inserted a ureteral catheter into the right side of his heart, and then descended a flight of stairs to confirm its position by x-ray. Later experiments, also performed on him, resulted in the first cardiac angiograms. Although heavily criticized by his superiors and the German medical establishment, Dr. Forssmann, an obscure urologist and general surgeon at the time, was eventually rewarded by sharing the Nobel Prize in 1956.

From the very beginning of surgery as a clinical science, surgeons have sat on the precipice of beneficial innovation versus unintentional harm to their patients. Because of the very nature of what they do, it has not usually been possible for them to self-experiment before testing their ideas on others. Every operation ever devised, occasionally with, but often without, animal experimentation, has had its initial human guinea pigs. In fact, surgeons have generally been given freer rein to try new and untested procedures or to modify older accepted ones. They have had greater license than have their counterparts who innovate with drugs and medical devices and are thus more tightly regulated by agencies such as the Food and Drug Administration.

In the best of circumstances, surgical patients are fully informed as to the potential consequences of a novel operation, both good and bad, and the results are carefully recorded to determine the benefit/harm ratio of the procedure. Ideally, though it is often not possible, the new approach is compared to a proven alternative therapy in a carefully designed trial. Unfortunately, such careful analysis has not always been done.

A glaring example of surgical human experimentation gone wrong is the frontal lobotomy story. In the early part of the 20th century, mental institutions in this country and throughout the world were filled with desperate patients for whom there were few therapeutic alternatives available. Many of these patients were incapable of giving meaningful informed consent. In 1935, frontal lobotomy was introduced by Antonio Moniz, a Portuguese neurologist, who later shared in a highly controversial Nobel Prize for his discovery. In 1946, an American neuropsychiatrist, Walter Freeman, modified the procedure so it could be done by psychiatrists with an ice pick–like instrument via a transorbital approach. A neurosurgeon performing a craniotomy, general anesthesia, and an operating room were no longer necessary, resulting in the rapid proliferation of this simpler operation despite its increasingly well-known and devastating side effects of loss of personality, decreased cognition, and even death. Only after more than 40,000 procedures were done in the United States did mounting criticism eventually lead to a ban on most lobotomies..

On the more noble side of surgical innovation, if Dr. Thomas Starzl and Dr. C. Walton Lillehei had not persisted despite failure after failure and death after death, liver transplantation and cardiac surgery would not have evolved to the lifesaving therapies they are today. These surgical pioneers and many others like them, who have persisted in the face of failure to develop new and useful approaches to surgical disease, can hardly be condemned for their human experiments that were disasters in the short term but enduring medical advancements in the long-term. Their initial patients were courageous, desperate, and hopefully well informed.

What separates these successful forerunners from those who promoted the lobotomy debacle? One factor may be history itself. Passed by Congress in response to the atrocities that had occurred earlier in the century, the National Research Act of 1974 mandated Institutional Review Boards (IRBs) in institutions conducting human research. Although the initial attempts at operating on the heart and transplanting the liver predated IRBs, much of the development of these specialties as we know them today took place under the watchful eye of these committees.

Whereas Freeman’s modifications made lobotomy a procedure that could be performed by almost anyone, cardiac surgery and liver transplantation required resources that could be provided only by major academic institutions.

While lobotomy almost became a traveling sideshow with poor documentation of results, the earliest attempts at heart surgery and liver transplantation were carefully recorded in the surgical literature for the entire academic community to analyze and ponder.

We owe much to those surgeons who persisted against great odds to develop our craft and to those patients with the courage to be a part of the great enterprise of surgical innovation. Without their daring, perseverance, and creativity, surgery would not have evolved to the diverse and noble specialty it is today. It is now incumbent upon us to make certain that future surgical innovation transpires only under an umbrella of safe, well-informed, and satisfactorily documented and controlled human experimentation.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

Ever since the earliest medical practitioners treated the first patients, a tension has existed between potentially beneficial innovation and unintentional harm. For many centuries doctors relied on their own experience or intuition to determine what was best for those whom they treated. It was not until the 17th century that Francis Bacon introduced the scientific method that consisted of systematic observation and testing of hypotheses. In the case of clinical science, this provided an objective means of determining which treatments would be in the best interest of patients. Since then, society has greatly benefited from remarkable medical advancements based on what is essentially human experimentation, much of it noble, but unfortunately some episodes quite tragic, misguided, and even demonic.

The most notorious human research abuses were those perpetrated by the Nazi regime during the Holocaust. There were only 200 survivors from the 1,500 sets of twins forced to participate in Josef Mengele’s infamous twin experiments at the Auschwitz concentration camp. Many of these investigations were genetic experiments intended to prove the superiority of the Aryan race. Little useful scientific information was gained from these inhumane and evil studies.

However, totalitarianism is not a prerequisite for mistreatment of human subjects. The American research community has its own checkered past. Possibly the most well-known abuse is the Tuskegee syphilis experiments that were conducted between 1932 and 1972 by the U.S. Public Health Service. Four hundred impoverished African American males infected with syphilis, who were not fully informed about their disease, were closely followed in order to record the natural history of this deadly and debilitating illness. These patients were not treated with penicillin although the drug became available in 1947. As a result, over one-third of the subjects died of their disease, many of their wives contracted syphilis, and numerous children were unnecessarily born with congenital syphilis.

On the other end of the ethical scale are a number of noble researchers scattered throughout history who insisted on experimenting on themselves before submitting others to their treatments or procedures. A prime example is a courageous and creative German surgical intern, Werner Forssmann, who paved the path to heart surgery through self-experimentation. Even into the 20th century, it was taboo for a physician to touch the living heart. Thus, much of its physiology and pathophysiology remained shrouded in mystery. In 1929, Dr. Forssmann did a cut-down on his antecubital vein, inserted a ureteral catheter into the right side of his heart, and then descended a flight of stairs to confirm its position by x-ray. Later experiments, also performed on him, resulted in the first cardiac angiograms. Although heavily criticized by his superiors and the German medical establishment, Dr. Forssmann, an obscure urologist and general surgeon at the time, was eventually rewarded by sharing the Nobel Prize in 1956.

From the very beginning of surgery as a clinical science, surgeons have sat on the precipice of beneficial innovation versus unintentional harm to their patients. Because of the very nature of what they do, it has not usually been possible for them to self-experiment before testing their ideas on others. Every operation ever devised, occasionally with, but often without, animal experimentation, has had its initial human guinea pigs. In fact, surgeons have generally been given freer rein to try new and untested procedures or to modify older accepted ones. They have had greater license than have their counterparts who innovate with drugs and medical devices and are thus more tightly regulated by agencies such as the Food and Drug Administration.

In the best of circumstances, surgical patients are fully informed as to the potential consequences of a novel operation, both good and bad, and the results are carefully recorded to determine the benefit/harm ratio of the procedure. Ideally, though it is often not possible, the new approach is compared to a proven alternative therapy in a carefully designed trial. Unfortunately, such careful analysis has not always been done.

A glaring example of surgical human experimentation gone wrong is the frontal lobotomy story. In the early part of the 20th century, mental institutions in this country and throughout the world were filled with desperate patients for whom there were few therapeutic alternatives available. Many of these patients were incapable of giving meaningful informed consent. In 1935, frontal lobotomy was introduced by Antonio Moniz, a Portuguese neurologist, who later shared in a highly controversial Nobel Prize for his discovery. In 1946, an American neuropsychiatrist, Walter Freeman, modified the procedure so it could be done by psychiatrists with an ice pick–like instrument via a transorbital approach. A neurosurgeon performing a craniotomy, general anesthesia, and an operating room were no longer necessary, resulting in the rapid proliferation of this simpler operation despite its increasingly well-known and devastating side effects of loss of personality, decreased cognition, and even death. Only after more than 40,000 procedures were done in the United States did mounting criticism eventually lead to a ban on most lobotomies..

On the more noble side of surgical innovation, if Dr. Thomas Starzl and Dr. C. Walton Lillehei had not persisted despite failure after failure and death after death, liver transplantation and cardiac surgery would not have evolved to the lifesaving therapies they are today. These surgical pioneers and many others like them, who have persisted in the face of failure to develop new and useful approaches to surgical disease, can hardly be condemned for their human experiments that were disasters in the short term but enduring medical advancements in the long-term. Their initial patients were courageous, desperate, and hopefully well informed.

What separates these successful forerunners from those who promoted the lobotomy debacle? One factor may be history itself. Passed by Congress in response to the atrocities that had occurred earlier in the century, the National Research Act of 1974 mandated Institutional Review Boards (IRBs) in institutions conducting human research. Although the initial attempts at operating on the heart and transplanting the liver predated IRBs, much of the development of these specialties as we know them today took place under the watchful eye of these committees.

Whereas Freeman’s modifications made lobotomy a procedure that could be performed by almost anyone, cardiac surgery and liver transplantation required resources that could be provided only by major academic institutions.

While lobotomy almost became a traveling sideshow with poor documentation of results, the earliest attempts at heart surgery and liver transplantation were carefully recorded in the surgical literature for the entire academic community to analyze and ponder.

We owe much to those surgeons who persisted against great odds to develop our craft and to those patients with the courage to be a part of the great enterprise of surgical innovation. Without their daring, perseverance, and creativity, surgery would not have evolved to the diverse and noble specialty it is today. It is now incumbent upon us to make certain that future surgical innovation transpires only under an umbrella of safe, well-informed, and satisfactorily documented and controlled human experimentation.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

I have been privileged to spend over one half of my 70 years on this planet as a surgeon. Even considering the innumerable highly stressful moments and the occasional failures in patient care that continue to haunt me, I cannot conceive of a more satisfying and enjoyable vocation. It saddens me to know that a significant percentage of those in our profession have not been able to gain a similar level of fulfillment from their lives in surgery as I have.

There is no doubt that a pall of negativity has descended upon the medical profession in recent years. The factors that have caused it are real – declining compensation in face of an increased workload, less autonomy in practice with a steadily increasing number of physicians and surgeons being employees rather than independent practitioners, an oppressive regulatory environment necessitating a seemingly endless amount of paperwork, and finally the uncertainty of what our profession will look like once health care reform settles into its final form.

These issues – along with the always-present stresses that accompany caring for sick patients and the challenge of balancing a too-busy professional life with a meaningful personal existence – have led to a shocking number of our colleagues experiencing the symptoms of burnout; emotional exhaustion, depersonalization, and a sense of low personal accomplishment.

It would be inappropriate for me to in any way minimize the effect that burnout is having on medical professionals. It is now a greater threat to surgeon wellness than any other dynamic, including alcoholism and drug abuse. I will deal with it in some detail in a future editorial. But here I would like to consider some of the unique and positive features that, in my opinion, still make surgery the most noble of professions and a career that we can highly recommend to our children and grandchildren. I sincerely hope that emphasizing the more upbeat and constructive aspects of our profession, most of which are obvious but are unfortunately obscured by the cloud of negativity, will provide at least a small beacon of light for those having difficulty seeing their way forward.

I feel compelled to admit to some important disclaimers. While I do not consider myself a Pollyanna, ever since reading a Dutch study (Giltay et al., Arch. Gen. Psychiatry 2004;61:1126-35) that showed an impressive difference in longevity between optimists and pessimists, I have solidly placed myself in the optimist camp. Additionally, I have spent my entire surgical career within the ivy-covered walls of academe. Finally, I fully realize that what brings joy to one person may not do so to another.

My basic assertion is that, while many aspects of our profession have changed, the basic core – the opportunity to make positive changes in the lives of others – remains solidly intact. As a surgical academician, this was not limited to just patients, but extended to medical students, surgical residents, and surgical faculty. I suspect in the private setting there are also numerous opportunities to mentor young colleagues and lend support to surgeons who are experiencing burnout or other issues that compromise the quality of their lives and their effectiveness as surgeons.

The most satisfying aspect of my practice was the nonmonetary rewards I received from grateful patients. The patient-doctor relationship that surgeons enjoy with their patients is particularly special. We alone among medical professionals have the opportunity to suddenly and dramatically alter the course of patients’ pain, suffering, and prognosis. We alone invade the sacred spaces of their bodies. Although what we do is based on science and anatomy, to many patients, it is almost in the realm of the supernatural. I have always thought that the designing and construction of a complex building is a more challenging feat than removing a diseased gallbladder, but patients don’t see it that way. If we are willing to simply maintain meaningful and kind communication with them, they freely and liberally express their gratitude for even minimal surgical achievements. When a life-threatening situation has been suddenly erased by a surgical operation, many consider it in the domain of the heroic.

Especially amazing to me is the generosity of patients and their families even when complications or death compromise the outcome. Occasionally, gratitude comes in the guise of a gift. The most memorable for me was an envelope labeled “Pennies from Heaven” that contained $2.83 designated for bile duct cancer research given to me by the grandchildren of a woman with that dread disease on whom I had operated. The sum may have been insufficient to have any scientific impact but was more than enough to brighten my day after I observed this lovely woman enduring a long, difficult, and eventually unsuccessful postoperative course (“Pennies from Heaven,” ACS Surgery News, December 2011, p. 18).

Aside from the privilege of caring for patients, the most rewarding element of my professional life has been the opportunity to mentor others. Nearly all of us who have had success in our profession have had one or more valuable mentors. Performing this function for others is not only appropriate, but, in a sense, represents a giving back for what others have done for us. An effective mentor provides a nurturing environment in which the mentee can reach his/her full potential. Whether you are helping a resident or junior associate better adjust to life as a surgeon or find their best career path, assisting them in achieving their goals is nearly as satisfying as successfully seeing a patient through a challenging operation and complicated postoperative course.

As difficult as life in surgery can often be, focusing on the unique positives – the appreciative patient cured of a life-threatening tumor, the skilled and accomplished senior resident who you helped train, the young associate who seeks your wisdom on difficult cases and becomes a better surgeon because of it – rather than the negative background of uncertainty and loss of control may help to confirm that what you are doing is worthwhile and most likely making the world a  better place.  

Dr. Rikkers is the editor in chief of ACS Surgery News. 

I have been privileged to spend over one half of my 70 years on this planet as a surgeon. Even considering the innumerable highly stressful moments and the occasional failures in patient care that continue to haunt me, I cannot conceive of a more satisfying and enjoyable vocation. It saddens me to know that a significant percentage of those in our profession have not been able to gain a similar level of fulfillment from their lives in surgery as I have.

There is no doubt that a pall of negativity has descended upon the medical profession in recent years. The factors that have caused it are real – declining compensation in face of an increased workload, less autonomy in practice with a steadily increasing number of physicians and surgeons being employees rather than independent practitioners, an oppressive regulatory environment necessitating a seemingly endless amount of paperwork, and finally the uncertainty of what our profession will look like once health care reform settles into its final form.

These issues – along with the always-present stresses that accompany caring for sick patients and the challenge of balancing a too-busy professional life with a meaningful personal existence – have led to a shocking number of our colleagues experiencing the symptoms of burnout; emotional exhaustion, depersonalization, and a sense of low personal accomplishment.

It would be inappropriate for me to in any way minimize the effect that burnout is having on medical professionals. It is now a greater threat to surgeon wellness than any other dynamic, including alcoholism and drug abuse. I will deal with it in some detail in a future editorial. But here I would like to consider some of the unique and positive features that, in my opinion, still make surgery the most noble of professions and a career that we can highly recommend to our children and grandchildren. I sincerely hope that emphasizing the more upbeat and constructive aspects of our profession, most of which are obvious but are unfortunately obscured by the cloud of negativity, will provide at least a small beacon of light for those having difficulty seeing their way forward.

I feel compelled to admit to some important disclaimers. While I do not consider myself a Pollyanna, ever since reading a Dutch study (Giltay et al., Arch. Gen. Psychiatry 2004;61:1126-35) that showed an impressive difference in longevity between optimists and pessimists, I have solidly placed myself in the optimist camp. Additionally, I have spent my entire surgical career within the ivy-covered walls of academe. Finally, I fully realize that what brings joy to one person may not do so to another.

My basic assertion is that, while many aspects of our profession have changed, the basic core – the opportunity to make positive changes in the lives of others – remains solidly intact. As a surgical academician, this was not limited to just patients, but extended to medical students, surgical residents, and surgical faculty. I suspect in the private setting there are also numerous opportunities to mentor young colleagues and lend support to surgeons who are experiencing burnout or other issues that compromise the quality of their lives and their effectiveness as surgeons.

The most satisfying aspect of my practice was the nonmonetary rewards I received from grateful patients. The patient-doctor relationship that surgeons enjoy with their patients is particularly special. We alone among medical professionals have the opportunity to suddenly and dramatically alter the course of patients’ pain, suffering, and prognosis. We alone invade the sacred spaces of their bodies. Although what we do is based on science and anatomy, to many patients, it is almost in the realm of the supernatural. I have always thought that the designing and construction of a complex building is a more challenging feat than removing a diseased gallbladder, but patients don’t see it that way. If we are willing to simply maintain meaningful and kind communication with them, they freely and liberally express their gratitude for even minimal surgical achievements. When a life-threatening situation has been suddenly erased by a surgical operation, many consider it in the domain of the heroic.

Especially amazing to me is the generosity of patients and their families even when complications or death compromise the outcome. Occasionally, gratitude comes in the guise of a gift. The most memorable for me was an envelope labeled “Pennies from Heaven” that contained $2.83 designated for bile duct cancer research given to me by the grandchildren of a woman with that dread disease on whom I had operated. The sum may have been insufficient to have any scientific impact but was more than enough to brighten my day after I observed this lovely woman enduring a long, difficult, and eventually unsuccessful postoperative course (“Pennies from Heaven,” ACS Surgery News, December 2011, p. 18).

Aside from the privilege of caring for patients, the most rewarding element of my professional life has been the opportunity to mentor others. Nearly all of us who have had success in our profession have had one or more valuable mentors. Performing this function for others is not only appropriate, but, in a sense, represents a giving back for what others have done for us. An effective mentor provides a nurturing environment in which the mentee can reach his/her full potential. Whether you are helping a resident or junior associate better adjust to life as a surgeon or find their best career path, assisting them in achieving their goals is nearly as satisfying as successfully seeing a patient through a challenging operation and complicated postoperative course.

As difficult as life in surgery can often be, focusing on the unique positives – the appreciative patient cured of a life-threatening tumor, the skilled and accomplished senior resident who you helped train, the young associate who seeks your wisdom on difficult cases and becomes a better surgeon because of it – rather than the negative background of uncertainty and loss of control may help to confirm that what you are doing is worthwhile and most likely making the world a  better place.  

Dr. Rikkers is the editor in chief of ACS Surgery News. 

I have been privileged to spend over one half of my 70 years on this planet as a surgeon. Even considering the innumerable highly stressful moments and the occasional failures in patient care that continue to haunt me, I cannot conceive of a more satisfying and enjoyable vocation. It saddens me to know that a significant percentage of those in our profession have not been able to gain a similar level of fulfillment from their lives in surgery as I have.

There is no doubt that a pall of negativity has descended upon the medical profession in recent years. The factors that have caused it are real – declining compensation in face of an increased workload, less autonomy in practice with a steadily increasing number of physicians and surgeons being employees rather than independent practitioners, an oppressive regulatory environment necessitating a seemingly endless amount of paperwork, and finally the uncertainty of what our profession will look like once health care reform settles into its final form.

These issues – along with the always-present stresses that accompany caring for sick patients and the challenge of balancing a too-busy professional life with a meaningful personal existence – have led to a shocking number of our colleagues experiencing the symptoms of burnout; emotional exhaustion, depersonalization, and a sense of low personal accomplishment.

It would be inappropriate for me to in any way minimize the effect that burnout is having on medical professionals. It is now a greater threat to surgeon wellness than any other dynamic, including alcoholism and drug abuse. I will deal with it in some detail in a future editorial. But here I would like to consider some of the unique and positive features that, in my opinion, still make surgery the most noble of professions and a career that we can highly recommend to our children and grandchildren. I sincerely hope that emphasizing the more upbeat and constructive aspects of our profession, most of which are obvious but are unfortunately obscured by the cloud of negativity, will provide at least a small beacon of light for those having difficulty seeing their way forward.

I feel compelled to admit to some important disclaimers. While I do not consider myself a Pollyanna, ever since reading a Dutch study (Giltay et al., Arch. Gen. Psychiatry 2004;61:1126-35) that showed an impressive difference in longevity between optimists and pessimists, I have solidly placed myself in the optimist camp. Additionally, I have spent my entire surgical career within the ivy-covered walls of academe. Finally, I fully realize that what brings joy to one person may not do so to another.

My basic assertion is that, while many aspects of our profession have changed, the basic core – the opportunity to make positive changes in the lives of others – remains solidly intact. As a surgical academician, this was not limited to just patients, but extended to medical students, surgical residents, and surgical faculty. I suspect in the private setting there are also numerous opportunities to mentor young colleagues and lend support to surgeons who are experiencing burnout or other issues that compromise the quality of their lives and their effectiveness as surgeons.

The most satisfying aspect of my practice was the nonmonetary rewards I received from grateful patients. The patient-doctor relationship that surgeons enjoy with their patients is particularly special. We alone among medical professionals have the opportunity to suddenly and dramatically alter the course of patients’ pain, suffering, and prognosis. We alone invade the sacred spaces of their bodies. Although what we do is based on science and anatomy, to many patients, it is almost in the realm of the supernatural. I have always thought that the designing and construction of a complex building is a more challenging feat than removing a diseased gallbladder, but patients don’t see it that way. If we are willing to simply maintain meaningful and kind communication with them, they freely and liberally express their gratitude for even minimal surgical achievements. When a life-threatening situation has been suddenly erased by a surgical operation, many consider it in the domain of the heroic.

Especially amazing to me is the generosity of patients and their families even when complications or death compromise the outcome. Occasionally, gratitude comes in the guise of a gift. The most memorable for me was an envelope labeled “Pennies from Heaven” that contained $2.83 designated for bile duct cancer research given to me by the grandchildren of a woman with that dread disease on whom I had operated. The sum may have been insufficient to have any scientific impact but was more than enough to brighten my day after I observed this lovely woman enduring a long, difficult, and eventually unsuccessful postoperative course (“Pennies from Heaven,” ACS Surgery News, December 2011, p. 18).

Aside from the privilege of caring for patients, the most rewarding element of my professional life has been the opportunity to mentor others. Nearly all of us who have had success in our profession have had one or more valuable mentors. Performing this function for others is not only appropriate, but, in a sense, represents a giving back for what others have done for us. An effective mentor provides a nurturing environment in which the mentee can reach his/her full potential. Whether you are helping a resident or junior associate better adjust to life as a surgeon or find their best career path, assisting them in achieving their goals is nearly as satisfying as successfully seeing a patient through a challenging operation and complicated postoperative course.

As difficult as life in surgery can often be, focusing on the unique positives – the appreciative patient cured of a life-threatening tumor, the skilled and accomplished senior resident who you helped train, the young associate who seeks your wisdom on difficult cases and becomes a better surgeon because of it – rather than the negative background of uncertainty and loss of control may help to confirm that what you are doing is worthwhile and most likely making the world a  better place.  

Dr. Rikkers is the editor in chief of ACS Surgery News. 

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News