Evidence and innovation in private practice: an evolving paradigm.

W ith all the talk about ‘‘transformation’’ in medicine, there are challenges ahead for each of us, no matter what our current practice status is. The impending change makes the need to remain current with medical knowledge and technological advances all the more crucial. Medicine has always been a lifelong learning experience over a 3to 4-decade career. Private practitioners, by virtue of their experience, have traditionally been well placed to contribute to the advance of medical innovation. To do so responsibly and effectively in today’s ‘‘best-practice’’ environment, however, may require an ongoing level of cooperation with medical organizations and academic institutions not previously considered. It is always desirable to have the reputation in one’s professional and social marketplace as a physician and surgeon who is current with their knowledge and skill. A worthwhile philosophy to maintain is to not rush introduction of new ideas or technology without testing, preassessment, and being sufficiently assured as to the benefits. In his book, The Tipping Point, Malcolm Gladwell provides a good presentation of the 5 lifecycle stages in the application of new ideas: innovators, early adopters, early majority, late majority, and laggards. In regards to medicine, there will always be those who desire to be first, even though there is the danger of also being among the first to make the early mistakes from which the rest of us will learn. When evaluating new ideas and introducing new technology, we need to remain cautious and deliberate thinkers. It is important to not become a ‘‘laggard’’ when a true innovation or technological benefit is recognized. It is equally important not to be perceived as ‘‘experimental’’ or ‘‘cavalier.’’ To try and better standardize care, our American Academy of Otolaryngology—Head and Neck Surgery Foundation has worked diligently to create a process to continuously update an expanding list of clinical practice guidelines, indicators, and consensus statements. It is understandably argued that these documents are designed to reduce bias and make it easier for all of us to consistently practice a uniformly high quality level of otolaryngologic medicine and surgery. This evidence-based initiative is a necessary and worthwhile endeavor with great intentions. However, despite the caveats, it is reasonable to counter that they may sometimes make it more difficult to adapt care to the specifics of an individual patient. There may also be restrictive financial impact based on insurance carriers’ different interpretations of the same documents. Further, most of the acceptable studies currently used in evidence-based medicine are generated by academic centers whose patient populations may not necessarily translate well to the patient population of our general membership in terms of various clinically relevant parameters The evidence-based medicine process of winnowing down sometimes hundreds of articles to analyze the relatively small number of ‘‘good’’ studies necessarily leaves out a potential wealth of experiential data with lower level ‘‘relevancy.’’ There is still value in the reporting of unusual case studies and ‘‘how I do it’’ articles, but they are now less desirable. The result of this process is that there will most likely be a greater incentive for developing and publishing more level I and II research, which is good, but such work takes time and a support system that is generally not available to the private practice physician. It has become more difficult, therefore, for the private practitioner to make a broader professional impact from his or her clinical experience. The majority of our membership remain in some form of private practice, and we would be wise to try and prevent an increased separation between those who make decisions from those who have to implement those decisions. Without the balance of expertise and evidence from all of our specialty, medical progress slows down. Steven Johnson writes in his book, Where Good Ideas Come from—The Natural History of Innovation, ‘‘When one looks at innovation in nature and in culture, environments that build walls around good ideas tend to be less innovative in the long run than more open-ended environments.’’ It is a cautious reminder, and we would benefit from creating a decision-making model that encourages input from all of our physicians