The Role of Objective Outcomes in Surgery in Overcoming Cognitive Dissonance

The quest for improved surgical outcomes in an era of evidence-basedmedicinecompelsus tomeasureandevaluateour outcomes. Aheightened awareness exists, not only of the importance of objectively measuring our outcomes in terms of function and form, but also of the challenges in doing so.2 Rhinoplasty in particular is quite challenging given the highly subjective nature of the outcomes we seek. Do our interventions produce the desired effect? As surgeons we routinelyperformmaneuversunder the assumption that they are not only effective but optimal. Are they? Would our intuition stand up to scrutiny? In this issue of JAMA Facial Plastic Surgery, Ozucer and colleagues3 evaluate the efficacy of a very simple, routine, but rarely investigatedmaneuver: the use of postoperative taping after rhinoplasty. The authors performed a prospective randomized clinical trial in which theyusedultrasonography tomeasure the thickness of the skin soft-tissue envelope after rhinoplasty,with andwithout taping.Reassuringly formost surgeonswhoplace tape, the method seems to work. Several options exist to measure the aesthetic outcomes after facial cosmetic surgery that tend to fall within 1 of the following 2 categories: patient-reported outcomes and objective clinical measures. Patient-reported outcomes that can be applied to rhinoplasty include measures such as the Rhinoplasty Outcomes Evaluation, a validated instrument developed to measure satisfaction with aesthetic improvement.4 As technology advanced, objective clinical measures have proliferated rapidly. These measures include the use of photogrammetry, 3-dimensional laser surface scanning, and other quantitative means to measure the effect of our intervention.5 Patient-reported outcomes are critically important. The purpose of elective aesthetic surgery in the end is to produce a psychological benefit for the patient. The patient’s perception of the outcome is the most important objective. However, we cannot rely solely on patient-reported outcomes in our field or any other field. Patients may report changes in symptoms after an intervention that cannot be confirmed by objectivemeasures. In the field of aesthetic surgery, objectivity in determining outcomes is limited for several reasons, including the challenges individuals have in visually perceiving their own faces accurately.6 Another dynamic not only distorts theviewsofourpatientson theiroutcome,but Iwould alsoargueexertsapernicious influenceonusassurgeonswhen we evaluate our own clinical choices and outcomes: cognitive dissonance. Cognitivedissonancewas firstdescribedbyFestinger.7This term refers to the mental discomfort experienced by an individual who holds 2 or more contradictory beliefs at the same time. Human beings strive for consonance—internal consistency—and so aremotivated to try to reduce this dissonance. If one belief (“I am a good father.”) is challenged by another belief or experience (“I haven’t seenmy kids in 5weeks.”), an unpleasant state results that canbe reducedby changing 1 belief or by rationalizing (“I am working this hard for the kids’ benefit!”).Aclassicexample is thatof thesmoker.Smokersmay deal with dissonance that is produced between their behavior (choosing to smoke, which is in dissonancewith the natural inclinationtoavoidharm)andthebelief that smoking ishazardous bydenial (“Mygrandfather smoked and lived til 90!”). Factors that increase the effect of cognitivedissonance include theexerciseof freechoiceandresponsibility, theamount of investment that the individual places into something (hard work, time, payment), and how painful or difficult something is.8 Thus, a young college student subjected to humiliating hazing rituals to join a fraternity reduces the cognitive dissonance of his choices to endure such abuse by creating a new belief (“I am not a complete moron for allowing myself Related article page 157 Effect of Postrhinoplasty Taping on Postoperative Edema Original Investigation Research