Abstract
Patients want dependable hands. Hand surgeons want to make a difference. Not just the type of ‘thanks, I feel better’ difference that often seems as achievable for salespeople as it is for scientists. We want to make the ‘stabilize the wobbly bone’, ‘help the elbow move by getting the extra bone out of the way’, ‘cure the life-threatening infection’ type of difference that drew us to hand surgery.
Patients are vulnerable. They ask, ‘What can be done for me?’. Both patients and surgeons tend to rely on their experience and intuition when searching for answers. But humans invented science because things are not always as they seem (Chabris and Simons, 2011; Kahneman, 2011).
We are at risk of fooling ourselves or being fooled by others. The human mind overestimates its capabilities. It is subject to simplification, isolation, framing, and other heuristics (automatic cognitive ‘shortcuts’ that we use to simplify complexity and manage uncertainty (Verma et al., 2014)). In order to truly make a difference, it is important to remain curious. We need to test hypotheses, and feel awe and wonder when our first impressions prove wrong. Indeed, to be aware of our illusions and catch them before they do harm.
I have always thought that one such useful system is to choose a wise fallback position (pre-emptive framing). For instance, why not assume that all new interventions are no better than older interventions or no treatment until science proves otherwise? Why not expect that the simplest, the most resourceful, efficient, readily available, practical, optimistic, enabling, and hopeful ideas and options are the best until we prove otherwise? For instance, think of all the trouble we can avoid if we assume that using your hands is healthy and cannot harm them. What if we assume that every patient is capable – given the right skills and circumstances – of adapting to adversity as well as the most resilient person we know? What if we assume that the cheaper treatment is better? Imagine how our practices would be if these were our baselines and if we trusted analysis more than intuition before changing our minds.
What is the future of hand surgery? It seems to me that we expend inordinate energy debating whether collagenase, nerve tubes, and volar locking plates are better than their predecessors. Meanwhile a substantial percentage of the world’s population stand to benefit from clean water, improved sanitation, education, routine vaccination, better access to medications, and safer surgery, among other things. I doubt there is any argument that the average patient’s request ‘what can be done for me?’ has different implications in Haiti compared with Boston. I am persuaded by Paul Farmer’s affirmation that the answer to the question should be similar in both places (Farmer, 2013).
I am most curious about the limited correspondence between objective pathophysiology and impairment (disease), and symptoms and disability (illness) in patients with hand and upper extremity conditions (Vranceanu et al., 2009), and the substantial variation in diagnosis (e.g. radial tunnel syndrome (Van den Ende and Steinmann, 2010)) and treatment (e.g. rates of carpal tunnel release in patients with mild or normal electrophysiological tests (Makanji et al., 2013)) among hand surgeons. In my estimation, science will have difficulty demonstrating an advantage of many of our discretionary surgeries (e.g. trapeziometacarpal arthroplasty) over adaptation and resiliency (Das et al., 2013); many of our surgeries will not out-perform sham surgery (Sihvonen et al., 2013) (e.g. radial tunnel release, debridement or suturing of the triangular fibrocartilage complex); and few of our treatments will outperform the natural history of the condition being treated (e.g. corticosteroid or platelet enriched plasma injection for tennis elbow (Szabo, 2009)).
I am also of the opinion that science will find that the use of ineffective biomedical treatments is counterproductive. For instance, when patients receive a corticosteroid injection for tennis elbow in spite of strong evidence that steroid injections are no better than placebo injections (Szabo, 2009), they are encouraged to consider what is essentially a benign rite of passage through middle age as a condition requiring treatment; they are encouraged to be passive and rely on caregivers for good health; and they miss an opportunity to learn and practice effective coping strategies, which seem – to date – to be the most effective protection against pain and disability.
Medicine is most inspiring in the treatment of pathophysiology (e.g. penicillin for streptococcal infection) and is more debatable when treating symptoms, for example hysteria, whiplash, repetitive strain injury (Lucire, 2003; Malleson, 2002; Shorter, 2008). Some of the most fulfilling hand surgeries are limb life and limb-saving debridement of necrotizing fasciitis or release of compartment syndrome; enabling an unstable humerus nonunion to heal; and allowing restful sleep and preventing nerve damage by releasing the transverse carpal ligament in a patient with electrodiagnostically confirmed moderate median neuropathy at the carpal tunnel. Examples of surgeries that are more unsettling and create discord are ‘decompression’ of the median nerve for pain in the forearm; first rib resection for vague, diffuse upper extremity pains; and surgery for ‘pre-dynamic’ scapholunate instability in patients with the ever-present nonspecific wrist pain. It seems to me that hand surgeons are at their best when they address pathophysiology and most subject to question when treating symptoms and disability in the absence of measurable pathophysiology.
In my opinion, the future of hand surgery rests on determining the best use of resources and the best investment of hope by placing a priority on treatments that are proved to be disease-modifying; by determining whether palliative treatments outperform the placebo effect (which is basically just adaptation and resiliency – our ‘inner healer’), regression to the mean, and the self-limiting course of many ailments; and by diminishing surgeon-to-surgeon variation in care. I am open to the possibility that science might determine that practiced and effective stress management and coping strategies are better for your musculoskeletal health than most discretionary medications and surgeries.