The Emperor’s New Surgery

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The Emperor’s New Clothes is a short story written by the Danish author Anderson,1 published in 1837. It narrates a tale of 2 conmen tailors who promise a vain egotistical Emperor a new set of clothes that are invisible to those who are incompetent, unfit for their position, or stupid. The Emperor, believing the conmen tailors, parades before his ministers and townsfolk in his new clothes, and not one individual says that they do not see any clothes, as they fear that they will be seen as unfit for their positions, incompetent, or stupid. This continues until an innocent child in the crowd blurts out that the Emperor is wearing nothing at all, and the townsfolk soon join in the laughter and commenting. The Emperor realizes that he is not wearing any clothes and—despite this—continues his procession more proudly, as his courtiers carry a train that is not even there.
Although there are several morals in the Hans Christian Anderson tale, the one most related to upper extremity and hand surgery would be that we should not believe things without empirical evidence. When this tale was published in 1837, the use of empirical evidence was gaining acceptance of explaining phenomena rather than relying on superstition and old wive’s tales. When scientists reported on their empirical data, many were harshly criticized and/or punished. The Hungarian physician Semmelweis’ recommendation for antiseptic hand washing in the maternity ward during the mid 19th century resulted in his incarceration in a mental asylum where he was beaten to death.2 Fortunately, the use of empirical evidence and reevaluation of data to support an outcome has become the basis of the scientific method.
More importantly, Anderson’s tale emphasizes the need for surgeons not to be the Emperor’s ministers or courtiers who remained silent for fear of being called stupid or incompetent, but to be the child who trusts and voices what he/she sees.3 Despite this, medical history is full of examples of how physicians and surgeons have worn the Emperor’s new clothes only to have empiric evidence demonstrate that the Emperor has no clothes. The consequences to patients can be devastating. Two such examples would be (1) the promotion of the “wonder drug” Thalidomide in pregnancy, which resulted in infant death and severe birth defects,4 and (2) the 1980 New England Journal of Medicine’s 5-sentence letter on the risk of opiod addiction, which stated that opiod addiction was rare.5
The continual struggle between innovation, the introduction of new technologies, and novel surgical procedures with academic advancement, company success, and individual fame makes Anderson’s 1837 tale even more relevant in 2017.
Over the past several decades, there have been several such surgical techniques that were introduced as a solution to a difficult problem, but ultimately demonstrated problematic outcomes. Over my 25-year career as an orthopedic surgeon, I have read and listened to the papers on devices and techniques that were suppose to revolutionize my outcomes (Pi plate for distal radius fractures, tenofix tendon repair device, orthosphere and Artelon for carpometacarpal arthritis, thermal shrinkage of the shoulder capsule, to name a few). After hearing and reading of what I now call the “Emperor’s New Surgery,” I tried these, did not get the expected outcome, and often attributed the failures to myself.
Energetic, enthusiastic, persuasive, or famous surgeons with new technologies/innovations/surgeries can often influence us to choose a new surgery/technology without a clear understanding of the empiric data.
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