From Art to Science: Patient-Reported Outcomes in Hand Surgery

A Brief History of Outcomes

Medicine has historically been viewed as an art rather than a science, and the outcome of an intervention is often reported without solid evidence to back up assertions. The history of bloodletting is a good example of this. Hippocrates believed that the basic elements of life (earth, fire, water, and air) were represented in humans by the four humors of blood, bile, black bile, and phlegm. Of these, blood was considered the dominant humor. Since the disease was thought to arise from an imbalance of these humors, bloodletting became popularized to restore harmony and thus cure disease. This belief prevailed until the mid-19th century when, in Edinburgh, Dr. Hughes Bennett observed that patients who were not subjected to bloodletting developed milder diseases than those who were. The practice slowly receded over the following years and is now considered the cause of death of many patients, including the American President George Washington, who died the day after bloodletting from shock.[1]

This early story of observing outcomes influencing practice has been paralleled over the years in medicine. Doctors have traditionally been slow to follow and change practices. One hundred years later, John Charnley developed his hip replacement and began implanting it in patients at the orthopaedic hospital in Wrightington in 1962. His early results were far superior to previous implants and the natural history of hip osteoarthritis. Over the following years, Charnley trained selected surgeons to implant his device. Within 20 years, hip replacement became the country's most-performed orthopaedic operation despite the lack of randomized controlled trials (RCTs) comparing total hip joint replacement to conservative management.[2]

In Scotland, the Scottish Arthroplasty project was established in the 1990s. Although patient-reported outcome measures (PROMs) are not recorded nationally, outcome measures such as death, revision, and readmission with complication are allowing surgeons to benchmark against their peers.

Hand surgery developed as a subspecialty of both Orthopaedic and Plastic Surgical practice after the Second World War, necessitated by the need for reconstructive surgery in mutilated or severely burned patients. In 1952, a group of surgeons in the United Kingdom interested in hand surgery formed the “Hand Club,” meeting regularly to discuss cases and socialize. This club, however, was exclusive and refused to admit new members. In 1956, the “Second Hand Club” became the current British Society for Surgery of the Hand (BSSH).

With the growth of the BSSH, interest in clinical outcomes developed, and in 1995 a conference was held to examine outcomes in hand surgery specifically. This discussion is documented in a paper outlining the conclusions of a working group.[3] The outcomes were broadly categorized as subjective or objective. The subjective outcomes were based on a series of questions on the patient regarding function and symptom level, with objective data assessed by the physician using measurement. These concepts were very quickly and widely adopted. Over the next 10 years, many sites and disease-specific outcome measures were developed in multiple centers. Data collection, however, remained a significant issue. Around 2010, most of these data were imputed by hand, and only some clinicians had the resources to collect patient outcome data.

In recent years, published research in hand surgery has grown exponentially, driven by the technology of the Internet, communications, and readily accessible statistics packages.

We have, therefore, seen a massive shift in how we define and measure a successful outcome as hand surgeons, moving from the art of the 20th century to the science of the 21st century, and how we rate our strength of evidence that becomes important if we are to interpret published scientific studies effectively.

Publication History

Article published online:
29 June 2023

• References

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