ROBERT W. ANDERSON, M.D.
DAVID C. SABISTON, JR., PROFESSOR AND CHAIRMAN
DUKE UNIVERSITY MEDICAL CENTER
DURHAM, NORTH CAROLINA

During the course of a 30-year academic career in surgery, I have been both a participant and witness to a number of revolutionary changes that have profoundly influenced the clinical practice of surgery. The driving forces behind these changes have been science, finances, and information. Each has played, and continues to play, an important role. However, it is increasingly apparent that information has become the dominant force in how we will deliver surgical care in the future, since it will provide guidance to those who will shape both scientific and financial policies in the practice of surgery and all of health care. Tools to support the practice of "evidence-based surgery" are in development and will become imperative as consumers and payers demand high-quality and cost-effective care as a mandatory and not just a desirable goal for society. It is important that surgeons be informed and proactive in this inexorable progression of events.

Following World War II, the U.S. federal government decided that medical science was useful and important, and research became a serious business. This led to the expansion of extramural research programs by the National Institutes of Health and strengthened the nation's capacity for medical science by building research into the core mission of American medical schools in addition to education and patient care. The results were initially spectacular, and the creativity of U.S. medicine was the envy of the rest of the world. With time, however, several problems became apparent. First, research became more expensive than anyone had ever predicted. Second, an increase in professional standards for health care, coupled with unrelenting patient demands and expectations, led to steeply rising costs for all medical care, particularly hospital costs. The 1980s saw demands for retrenchment in all government programs, and an era of cost-cutting began that initially had a profound impact on health care delivery and costs but has proven to be unsustainable for many reasons.

Many of the technological advances in surgery have been expensive and have been identified as the culprits in uncontrolled expenses for the delivery of surgical care. Although technology is blamed for this phenomenon, the problem appears to be more related to our failure to validate the effectiveness of technology, to overuse technology, and to unnecessarily reduplicate technology.

The only solution to the problems we are confronting in the delivery of surgical care would appear to be the application of carefully validated information developed by surgical scientists and clinicians who acquire and practice peer-reviewed skills with high proficiency. This will be the goal of evidence-based surgery and will demand immediate access to critically appraised information that is both current and valid. Traditional sources of information, such as textbooks, journals, and conferences, are limited in their ability to achieve these goals.

After careful consideration of how decisions could most readily be made available at the point-of-care by accessing the most up-to-date and validated information, the Department of Surgery at Duke University agreed to collaborate with Unbound Medicine, Inc., an innovative publisher of digital material. The result is Unbound Surgery, a digital information resource that is designed to be authoritative, up-to-date, useful in clinical practice, and adaptable to various communication devices.

The editors of Unbound Surgery, Drs. Theodore N. Pappas and Gretchen P. Purcell, have designed a format that allows Unbound Surgery to serve as both a comprehensive reference source and effective question-answering tool. The standardized format aids authors in preparing material while allowing readers to easily browse detailed chapters for specific topics on diagnosis or treatment, review techniques, and perform precise electronic searches on carefully specified topics in a facilitated yet comprehensive manner.

Unbound Surgery represents a new approach to managing surgical information through the application of state-of-the-art information technology. I believe it sets a new standard, and I congratulate the authors, editors, and publishers on their accomplishment. The development and application of new methods of information management resources will form the basis of evidence-based surgery and lead to cost-effective care that is of the highest quality and will result in the best outcomes for patients.