POEMs (Patient-Oriented Evidence That Matters): The Surgeon's Poetry

Artists and Critics 

Surgeons have more than a casual unwillingness to address science, as science is meant to be used. After all, surgery is an art. That is the source of both its richness and its poverty. As an art it brings health and beauty to our patients, but as with all art, its results are only measured by the pleasure of its viewers.

While one might imagine this state of the surgeon's profession for cosmetic surgery alone, for oral and maxillofacial surgeons it is equally true for areas as diverse as orthognathic surgery, tumor reconstruction, implant surgery, and trauma surgery. Comments in symposia such as—“That chin is way too big. Can you believe the poor bone stock in that reconstruction? Check out the black holes in the emergence profile. Will you look at those bone plates?”—indicate that the art of surgery, not its objective outcomes, has a far greater effect on the audience of surgeons. Some surgeons even carry this to extremes with a visceral aversion to evidence-based medicine. These surgeons believe that clinical research is not a useful guide to practice. Observing some of our JOMS readers, especially residents, often the photographs in the paper make a better case for a clinical investigation than the study that the illustrations support. This is not to disparage the importance of visual understanding in clinical surgery research, but the illustrations often make the case for the clinical science. Recently a patient was presented at conference with pan facial fractures and comminuted condylar head fractures. Clearly the patient would benefit from open reduction but the participants were skeptical that it should be done or could be accurately achieved. While results of the case series of He et al1 presented in JOMS regarding the efficacy of this method held some sway in determining treatment, opening the PDF showing the beautiful accompanying illustrations of this technique was needed to gain the acceptance of the conference participants.

As our surgery shapes and molds, it seems to defy measurement. (Hence, insurers and policy makers eschew CPT codes with “plasty” in the title.) Even attempts to measure surgical outcomes are met with skepticism by surgeons who feel far more confident with how an approach to a clinical problem or a procedure works in their hands rather than relying on the measured experience of others. Their subjective and very personal (artistic) assessment of patient outcome carries far greater weight to them than an objective listing of essential outcome variables produced in a randomized clinical trial.

Clinical scientists are often seen by surgeons as critics. The surgeon, cast here as impetuous artist, can view criticism as an affront to their art. For example, imagine the reaction of cardiothoracic surgeons to the clinical research that showed image-guided stenting worked as well as coronary artery bypass grafts (CABGs) for coronary artery occlusion and with less morbidity. They rejected the work as being from investigators not “in the trenches” not understanding the inestimable goodness, and beauty, they had achieved with the CABG.

The movie critic, the art critic, the literary critic all tend to be dismissed by their respective artists. The critic is often seen by the artist as a failed artist. Those who can, do; those who cannot, criticize. For the art of surgery, those who can do; and those who cannot, do clinical research. The presentation of research can be taken personally by surgeons when the findings do not match their artistic notion of the surgery.

How can the surgeon balance his or her art with the criticism of clinical science? The answer is POEMs, the surgeon's poetry.

POEMs 

The concept of patient-oriented evidence that matters (POEMs) was developed by David Slawson and Allen Shaughnessy2 to address this issue of art and science. POEMs are the clinical papers that offer laser-like findings that can improve surgical practice. They can offer guidance as to diagnosis, treatment planning, and surgical methods.

POEMs address an important clinical issue in practice, measure an outcome of importance to both surgeon and patient, and offer the potential to change the way we practice. In order to be a POEMs, experienced clinicians usually design a study to address a problem they have faced. As such, POEMs is a melding of the art and science of surgery.

In reading this month's JOMS, look for POEMs and as an artistic surgeon assess your reaction, both visceral and intellectual to these investigations and the clinical recommendations that can follow from their conclusions.

Important clinical questions are addressed in papers with Patient-Oriented Evidence That Matters for your consideration in this issue:

Read the science and consider your art. You will discover that the division between art and science is artificial. It is no accident that Slawson and Shaughnessy alluded to art in the term POEMs, since good clinical research is poetry, and is beautiful.