Guidelines in Neuromodulation: Education in the Era of Evidence (Ignorance?) Based Medicine

Let me first begin by announcing that Neuromodulation: Technology at the Neural Interface has just been awarded the honor by the National Library of Medicine of being indexed and included in MEDLINE. Citations from the articles indexed, the indexing terms, and the English abstract printed in the journal will be included and searchable using PubMed. Over the past two years, since I have assumed the position of Editor-in-Chief, we have been devoted to this critical goal for the success of our journal and the growth of our specialty. Through the tireless assistance of our Associate Editors, our Editorial Board, our reviewers and authors, and our editorial staff, Tia Sofatzis (Managing Editor) and Mary Bockman (Editorial Assistant), we submitted our application in March of this year and we have just been informed of its success. I want to thank all of you for your ongoing support of the journal and solicit your contributions and submissions which will now be MEDLINE indexed for global discovery of your papers. In recent issues of Neuromodulation, two important articles help to define and clarify the practice of spinal cord stimulation. Presenting incidence and prevalence data for the risk of neurologic injury with surgically implanted paddle type spinal cord stimulation leads, a panel of experts then provided a consensus opinion concerning best medical practice for the pre-, intraand postoperative care of patients using these devices (1). Krames and colleagues (2) use the S.A. F.E. (Safety, Appropriateness, time to Fiscal neutrality and Efficacy) approach to decision analysis to elucidate the role of spinal cord stimulation for failed back surgery syndrome. While I believe these two articles to be both robust and reliable sources of medical information, neither is based solely upon principles of evidence-based medicine. One discusses a new context for clinical decision making based upon a multifactorial meta-analysis of the literature combined with the authors’ clinical experience while the other is based upon over a century of combined clinical experience among a group of six internationally recognized experts. As a journal editor, I am challenged by the suggestion that such important contributions should be discounted or discarded simply because their conclusions are not based upon Class I randomized controlled trials. While formal meta-analyses of high quality medical peer reviewed publications and randomized controlled trials will always be the gold standard for reliability for medical literature, we should not forget that important teaching can be communicated through other less “evidence based” vehicles. When I began medical school, the prevailing model of clinical medical education had not changed significantly from that of medieval apprenticeship. After largely indentured servitude to a master craftsman, the apprentice learned the craft of his mentor and carried on his practice and traditions. During our preclinical years in medical school, we were taught to read and memorize large volumes of information covering anatomy, physiology, pharmacology, etc., but our clinical years were marked by careful observation and mimicry. I closely observed Dr. Irvin Yalom’s masterful orchestration of group psychotherapy (3) and he then critiqued my sophomoric attempts to recreate a therapeutic environment. As a novice neurosurgical resident, I was awed by Dr. Charles Wilson’s effortless transsphenoidal approach to resection of a pituitary tumor; the next week I was unrealistically expected to flawlessly recreate his approach. Somewhat more germane to this journal, I carefully observed Dr. Yoshio Hosobuchi, one of the fathers of the field of neuromodulation, perform spinal cord and deep brain stimulation procedures. With a strong Japanese accent and a teaching philosophy that expected learning to occur as a result of a Zen-like osmosis rather than verbal instruction and explanation, Dr. Hosobuchi transmitted his knowledge in inscrutable but powerful ways. To be sure, there were benefits and drawbacks to these teaching approaches. The one on one approach allowed for true real time Figure 1. The Anatomy Lesson of Dr. Willem van der Meer by Pieter van Mierevelt (1596–1623). Delft.