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Eur J Cardiothorac Surg 2006;30:819-824
© 2006 Elsevier Science NL

Editorials

The evidence on which to base practice: different tools for different times

Guy's Hospital, London SE1 9RT, UK

(Email: Tom.Treasure@ntlworld.com; tom.treasure@ukgateway.net).

The first 300 words of the full text of this article appear below.

The tangible reward of clinical surgery is that with our own hands we change the course of disease and so improve and prolong our patients’ lives. That is what we find so compelling. From earliest times the goals of surgery were to staunch haemorrhage, to relieve obstruction and to drain pus. These simple tasks remain the most dramatically effective things we do. Every time we save a patient who is bleeding to death from a simple stab wound or a complex aneurysm; or when we relieve obstruction of a coronary artery, a heart valve, the oesophagus or trachea; and when we drain an empyema and see the improvement in a sick and toxic patient within hours, it is our knowledge, our skill and our craft that benefit the patient. These treatments are based on our knowledge of anatomy, physiology, pathology and the natural history of disease. We apply our knowledge in a rational and logical way; we see a direct cause and effect between what we do and the benefit we give.

In terms of evidence this can be simplified to the parachute analogy—you would be very foolish to try to fall to earth without one [1]. No trial will now be done of the parachute. Much of surgery may be viewed in that way. No trials will be done to test the fundamental principles of hip replacement, cataract surgery or valve replacement for aortic stenosis. In each case there is a clear mechanical cause for the effects of the disease and in each case they can be rectified by surgery. In these examples the effect is large and the relationship clear so no trials are needed. When the effect is small, or the cause and effect relationship is less obvious, or it is obscured by other factors, we . . . [Full Text of this Article]

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