Philosophical Reflection Around Ways To Improve Joint Replacement Outcomes!

Advanced expertise

High quality results are often generated by professionals with advanced expertise in their field. Achieving this expertise is likely to be the result of sound knowledge acquired through hard work by talented individuals with additional specific personality traits (attention to detail, a sense of refinement/sophistication, resilience, pro-activity, open-mindedness, curiosity, creativity, etc.). Many improvements made by human beings have been done so by top achievers, be it individually or alongside others. For a long time, medicine has advanced following a similar model, whereby highly observant doctors have made decisions based mainly on their experience (“Eminence-Based” Medicine). While this has led to significant breakthroughs in healthcare, there have been considerable costs.

inconveniences of ancestral medical practice

The inconveniences of ancestral medical practice were primarily the high heterogeneity in terms of quality and outcome between different geographical areas, and the difficulty in comparing true values. Comparison between techniques/practice was difficult and imprecise, as individuals defended their philosophy without proper supportive data. These limitations explain the increased involvement of science in medicine and the promotion of the Evidence-Based decision-making philosophy, also known as “Evidence-Based” Medicine (EBM).

scientific Aristotelian revolution

This scientific Aristotelian revolution in the medical area has now been widely accepted, and has already generated huge improvements, benefiting both patients and society. For instance, science enables us to screen for bad practice, poor surgical concept or poor implant design, etc. A good illustration of this is the National Joint Registry in its capacity as an audit tool, highlighting the inferior outcomes of certain hip resurfacing implants. Science enables the introduction of new techniques and implants in a stepwise manner, thus preventing spread of potential failure, to the benefit of patients. However, as for every concept, EBM has several drawbacks that are important to consider.

lack of recognition of relevant nuances

The care promoted by EBM tends to be systematic, generated through the use of guidelines which tend to be of low-level refinement. This is likely to prevent the worst, but also the best practice, by way of a lack of recognition of relevant nuances and a loss of the capacity to adapt to unusual situations. It is important to consider and be aware of the importance of nuances, the well-known “art of nuances” in Latin countries, when assessing the value of conclusions from EBM. EBM involves a pooled assessment of an inhomogeneous group of patients, generating average data that often neglects patient specificity. An allegory can be found in the Greek myth of Procrustes: midgod and son of Poseidon. Procrustes kindly invited people to his home, laid them on an iron bed, and adjusted their leg length (stretching up or chopping down), as he considered the size of the iron bed to represent the ‘normal’. This mistake of considering a single value to be normal, neglecting the fact that the normal lies within individual differences, led to Procrustes being punished by death by the god Theseus.

allegory of the cave from Plato

Further to this, advanced academic education tends to bring certitudes, often resulting in people losing their creativity, instead defaulting to following guidelines. It is important to be mindful thats guidelines are based on scientific conclusions, often drawn from data that is biased and inadequately interpreted, a drawback unfortunately inherent to research. The consequence of this loss of creativity may go unrealised for decades. A good illustration is the concepts of alignment of implants in total hip and knee replacement; it took approximately fifty years to challenge and condemn the non-physiological, intrinsically limited, traditional Mechanical Alignment techniques for implanting hip and knee components. This could have been avoided with the introduction of new concepts earlier, if the surgical environment had been more flexible or open-minded. Again, a good analogy can be found within the allegory of the cave from Plato: chained inmates spent their lives facing a wall with moving shadows, considering this to be the normal world; an escaped inmate discovered the truth and reported back to his fellow inmates, but this was insufficient to make anyone change their vision, as the latter was considered insane. Our knowledge is continually improving and gold standard concepts are often being challenged. Nevertheless, as in the allegory of the cave, discoveries that challenge the supposed EBM dogma are often poorly understood initially and opposed intensely, thus making life hard for the conceivers and potentially result in a detrimental loss for us all.

the Platonian and Aristotelian

The aim of this manuscript is not to be iconoclastic, but rather to raise awareness that although EBM is a great way to improve healthcare, there are risks which are not negligible. Medicine is facing a duality, dating from the antique ages, between the Platonian and Aristotelian (figure 3). While both philosophies represent different advantages and inconveniences, it is likely that an optimal surgical practice can be generated by accounting for both. After the EBM revolution started during the 19th century, mentalities switched to an extreme. With the current trend towards ‘personalised’ medicine, it is probably the appropriate time (the Kairos) for a new paradigm shift, which would emphasise the necessary integration between traditional “Eminence-Based” and recent “Evidence-Based” approaches, in order to refine health care and obtain optimal outcomes for our patients.

Let us rethink Raphael's School of Athens: Socrates points upwards to the imperishable things of the spirit; Aristote, designates downward, in the direction of things of matter. Attitude to life that are described there!

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The Kairos by Francesco Salviati