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How surgeons decide when the evidence is inconclusive
Michiel Hageman, MD; Thierry Guitton, MD, PhD; David Ring, MD, PhD;
Massachusetts General Hospital


Background: Patients and health care providers use scientific evidence to guide their medical decisions. This study addresses the factors that surgeons use to decide between two options when the evidence is inconclusive. Specifically, we tested the null hypothesis that these factors do not vary by training, demographics, and practice.

Methods: Three hundred thirty seven surgeons were asked to rate the importance of 7 factors when deciding between treatment and the natural history of the disease and 12 factors when deciding between two operative treatments using a 5-point Likert scale between very important and very unimportant.

Results: According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and the natural course of the illness were: “Works in my hands” (86%), “Familiarity with the treatment” (77%) and “What my mentor taught me” (66%). The most important factors when evidence shows no difference between two surgeries were: “Fewer complications” (99%), “Quicker recovery” (97%), “Burns fewer bridges” (90%), “Works in my hands” (89%) and “Familiarity with the procedure” (89%).

Europeans rated “Works in my hands” (p = 0.023) and “Cheapest/most resourceful” (p = 0.049) of significantly greater importance and “What others are doing” (p = 0.018), “Highest reimbursement” (p = <0.01) and “Shorter procedure” (p= 0.016) of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated “What my mentor taught me” (p < 0.01), “What others are doing” (p < 0.01) and “Highest reimbursement” (p < 0.01) of significantly lower importance compared to observers with 10 or more years in independent practice.

Conclusions: Surgeons deciding between two treatment options fall back to factors that relate to their perspective and reflect their culture and circumstances, moreso than factors related to the patient’s perspective when the evidence is inconclusive, although this may be changing among younger surgeons.

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