Surgery in the Era of Evidence-Based Medicine: The Decision-Making Dilemma Under Uncertainty

Stavytskyi V.V.

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Surgery in the Era of Evidence-Based Medicine: The Decision-Making Dilemma Under Uncertainty

October 14, 2026

Stavytskyi V.V.

УДК: УДК 617-089:001.89

DOI: 10.32471/umj.1680-3051.281551

Keywords :

adaptive expertise,

clinical judgment,

defensive medicine,

evidence-based medicine,

IDEAL framework,

protocol blindness,

randomized controlled trials,

surgical decision-making

Resume

Modern medicine, under the influence of the evidencebased paradigm, strives to unify clinical decisions. However, the institutionalization of Evidence-Based Medicine (EBM) has led to its
bureaucratization, converting the hierarchy of evidence into
a monopoly of randomized controlled trials (RCTs). This creates
a sharp ontological and methodological conflict in surgical practice, where each intraoperative act is unique and decisions are
made under strict time constraints and high uncertainty.

Aim:
to perform a methodological and epistemological analysis
of the limitations of EBM applicability in surgery and to substantiate pathways for overcoming the crisis of «protocol blindness»
and «defensive medicine».

Materials and methods. A comprehensive philosophical and methodological analysis was applied,
including comparative analysis (matching therapeutic and surgical research designs), conceptual modeling based on the IDEAL
framework, cognitive science, and heuristic theory, alongside
historical-clinical deconstruction of surgical paradigm shifts.

Results. It was demonstrated that the classic RCT design faces insurmountable methodological barriers in surgery: operator-dependency, learning curve effects, impossibility of double-blinding, and
intervention complexity. The dangers of extrapolating average
population statistics onto the unique ontology of an individual
patient were analyzed. Using the concept of Damage Control
Surgery as an example, it was shown that stepping outside traditional protocol boundaries in critical conditions significantly reduces mortality. The role of alternative methodologies, particularly the IDEAL framework, for accumulating valid evidence was
substantiated.

Conclusions. Resolving the methodological crisis
requires returning to the authentic EBM triad, maintaining a dynamic equilibrium among external evidence, embodied clinical
expertise, and individual patient values. Surgery necessitates
epistemological pluralism, where standardization does not suppress clinical autonomy and adaptive expertise.

References

1. Feinstein A.R. (1967) Clinical Judgment. Baltimore, MD: Williams & Wilkins Co., 414 p.
2. Stavytskyi V.V. (2026) Evidence-Based Medicine: Sackett and Guyatt — The schism at the outset. UMJ, 178(4): 190–193. doi: 10.32471/umj.1680-3051.278401.
3. Sackett D.L., Rosenberg W.M.C., Gray J.A.M. et al. (1996) Evidence based medicine: what it is and what it isn’t. BMJ, 312(7023): 71–72. doi: 10.1136/bmj.312.7023.71.
4. Stavytskyi V.V. (2026) Evidence as Myth: Cognitive Traps of Evidence-Based Medicine in the Age of Scientific Absolutism. Reflections of a Clinician. UMJ, 175(1): 116–120. doi: 10.32471/umj.1689-3051.273809.
5. Meakins J.L. (2003) Surgery in the era of evidence-based medicine. Archives of Surgery, 138(1): 75–80. doi: 10.1001/archsurg.138.1.75.
6. Greenhalgh T., Howick J., Maskrey N. (2014) Evidence Based Medicine Renaissance Group. Evidence based medicine: a movement in crisis? BMJ, 348: g3725. doi: 10.1136/bmj.g3725.
7. Miles A., Loughlin M., Polychronis A. (2007) Medicine and evidence: knowledge and action in clinical practice. JECP, 13(4): 481–503. doi: 10.1111/j.1365-2753.2007.00923.x.
8. McCulloch P., Taylor I., Sasako M., Lovell B. (2002) Randomised trials in surgery: problems and possible solutions. BMJ, 324(7351): 1420–1423. doi: 10.1136/bmj.324.7351.1420.
9. McCulloch P., Altman D.G., Campbell W.B. et al. (2013) IDEAL framework for surgical innovation 1: the idea and development stages. BMJ, 346: f3012. doi: 10.1136/bmj.f3012.
10. Ergina P.L., Cook J.A., Blazeby J.M. et al. (2009) Challenges in evaluating surgical innovation. The Lancet, 374(9694): 1097–1104. doi: 10.1016/S0140-6736(09)61086-2.
11. Bunge M. (2012) Philosophy of Medicine. New York, Springer, 245 p.
12. Norman G.R. (2005) Clinical reasoning: 30 years later. Medical Education, 39(1): 118–124. doi: 10.1111/j.1365-2929.2004.02014.x.
13. Moulton C.A., Regehr G., Mylopoulos M., MacRae H.M. (2007) Slowing down when you should: a new model of expert judgment. Academic Medicine, 82(10 Suppl.): S109-S116. doi: 10.1097/ACM.0b013e3181494c41.
14. Gigerenzer G., Gaissmaier W. (2011) Heuristic decision making. Annual Review of Psychology, 62: 451–482. doi: 10.1146/annurev-psych-120709-145346.
15. Rotondo M.F., Schwab C.W., McGonigal M.D. et al. (1993) «Damage control»: an approach for improved survival in exsanguinating penetrating abdominal injury. The Journal of Trauma, 35(3): 375–382. doi: 10.1097/00005373-199309000-00008.
16. Holcomb J.B., Jenkins D.H., Rhee P. et al. (2015) Damage control surgery in the era of modern combat casualty care. Journal of Trauma and Acute Care Surgery, 79(6): 1243–1249. doi: 10.1097/TA.0000000000000876.
17. Smith G.C.S., Pell J.P. (2003) Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ, 327(7429): 1459–1461. doi: 10.1136/bmj.327.7429.1459.
18. Sutton P.A., Hornby S.T., Vimalachandran D., McNally S. (2015) Instinct, intuition and surgical decision-making. Bulletin of the Royal College of Surgeons of England, 97(8): 345–347. doi: 10.1308/rcsbull.2015.345.
19. Bennett N., Lemoine G.J. (2014) What VUCA really means for you. Harvard Business Review, 92(1/2): 27. doi: 10.5465/AMR.2014.0042.