To the Editor:
Commendably, the Journal of Hand Surgery continues to evolve and improve the quality of its articles. Recent enhancements include the designation of clinical studies by levels of evidence ranging from the highest (ie, high-quality randomized control trials) to the lowest (ie, expert opinion) (see http://www.jhandsurg.org/authorinfo). Even the Review Section has sought improvement with articles on Current Concepts, Surgical Technique, and Evidence-Based Medicine.
Although I applaud these changes, I am concerned by this statement in Budoff's recent technique article.
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It says:Although closed reduction with percutaneous pinning and immobilization may have been previously recommended for definitive treatment, better results have been achieved with open reduction, ligament repair, and internal fixation, which is now the current standard of care.2,3[Emphasis mine].
This statement is unsupported by any data. Rather, it references
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other technique articles neither of which reports even level IV evidence and is reminiscent of the Hans Christian Andersen story about the emperor's new clothes.Editors should be extremely wary of allowing the phrase “the current standard of care” in a peer-reviewed journal because in our litigious society, this is like filling a room with flammable gas in which a match will later be lit. Pity the poor hand surgeon whose patient receives less than an optimal result after treatment for a perilunate dislocation if he did not follow Budoff's recommendation and later has to explain this suboptimal result to a jury.
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Did Budoff really mean to use the phrase “standard of care” or did he mean to say “state of the art”? There is a world of difference between the two: the first is a legal term, whereas the second implies the “latest available.” If indeed the Journal's editors continue to allow authors to state that a given diagnosis or treatment is the “standard of care,” then the editors have a duty to the readers to issue a disclaimer such as the one that prefaces the American Society for Surgery of the Hand Self-Assessment Examinations:
The material is not intended to represent the only, or necessarily best, methods or procedures appropriate for the medical situation discussed. Rather it is intended to present an approach, view, statement or opinion of the authors … which may be helpful, or of interest, to other practitioners.5
If Budoff did not mean to use the term “standard of care,” then he should clearly state that this was not his intention in responding to this letter.
It appears that the Scientific Article section of the Journal mandates that any level IV paper include in its discussion the fact that its conclusions were limited by the quality of the data. On the other hand, the Review Section of the Journal seems to allow level V opinions with neither question nor critique. The policy disconnect between the Journal's sections recalls the old saying about the right hand not knowing what the left hand is doing—the ultimate irony for a hand journal.
References
- Treatment of acute lunate and perilunate dislocations.J Hand Surg. 2008; 33A: 1424-1432
- Carpal dislocations.Hand Clin. 2006; 22: 485-500
- Acute dorsal trans-scaphoid perilunate fracture dislocations: medium-term results.J Hand Surg. 2002; 27B: 498-502
- “Standard of care” for immediate breast reconstruction.Plast Reconstr Surg. 2001; 107: 1612
- 2008 Self-Assessment Examination.American Society for Surgery of the Hand, Rosemont, IL2008 (:2)
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© 2009 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
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- In ReplyJournal of Hand SurgeryVol. 34Issue 3
- PreviewThank you for the opportunity to reply to the letter by Dr. Freshwater. Dr. Freshwater takes exception to the phrase “standard of care” in the following passage: While closed reduction with percutaneous pinning and immobilization may have been previously recommended for definitive treatment, better results have been achieved with open reduction, ligament repair and internal fixation, which is now the current standard of care.
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