‘Opinion leaders are losing ground in the era of evidence-based medicine’

Oh Chang-wan

President in Department of Neurosurgery, Seoul National University College of Medicine

Oh Chang-wan, a renowned neurosurgeon and researcher in Korea, established the country’s first clinical guidelines for stroke treatment in cooperation with other experts. It took more than eight years to finish the work.

There was a time when some big-name doctors had enormous influence in medical circles in Korea. However, as the nation’s medicine moves toward an evidence-based era, they are increasingly losing ground, a renowned neurosurgeon said. “The emergence of evidence-based medicine means that the time of heroic tales of a few great doctors is over,” Oh Chang-wan, director of the Clinical Neuroscience Center at Seoul National University Bundang Hospital (SNUBH), said in an interview.
“The opinions of so-called ‘star doctors’ used to matter much when Korea had no one else to rely on, but today, doctors are using evidence from clinical research to make the best possible medical decisions for patients. What matters now is only the facts.” Evidence-based medicine is an approach that emphasizes the use of research data rather than experience. For example, clinical data collected from stroke patients help a surgeon decide how to treat a patient with a certain disease pattern. In other words, the approach uses proven methods rather than a doctor’s personal experience or insight to determine how to treat patients. Thanks to the clinical data that have accumulated over the past few decades, as well as the Internet, which gives doctors in Korea access to the latest information on best treatment methods, a paradigm shift is occurring in the country’s medical industry, Oh noted. “So much knowledge is required to understand each medical field today and there is a limit to how much knowledge one doctor can create or even grasp,” he said. “Thus, cooperation among doctors and systematic support for creating and accumulating knowledge are becoming ever more important in the medical world.” For example, the number of patients with cerebral artery diseases in Korea has increased to about 20,000 from 4,000 over the past 20 years.
“This is too much for one doctor to experience. Without cooperation, it would be very difficult to conduct meaningful research,” he said. When evidence-based medicine started gaining ground in the United States 30 years ago, Oh was beginning his career as a neurosurgeon. As the new concept started to spread to other academic fields and to other countries such as Japan, he pondered about his role in Korea. Which research issues should be addressed, how evidence should be collected and how results should be incorporated into clinical practice? Issues like these, he thought, would be critical in the future. So the opening of SNUBH in 2003 was a great opportunity for Oh. At that time, hospitals in Korea were regarded as nothing more than medical care providers, but SNUBH, the nation’s first paperless hospital, was built to serve also as a center for medical research. The hospital’s management of clinical data became much convenient, thanks to its adoption of an all-digital system, which other major hospitals in Korea later adopted. In his field of cerebrovascular disorders, his most urgent task was to establish objective clinical practice guidelines for stroke treatment. It was necessary not only to educate neurosurgeons across the country but also to convert their clinical practices into useful data instead of not utilizing them. Oh contributed to the establishment of Korea’s first clinical guidelines for stroke treatment in 2006, which were finished more than eight years later. The renowned stroke expert has also held workshops about surgical techniques for other doctors across Asia.

From imitation to innovation

Over the past few decades, Korea’s medical industry has greatly improved. Oh said now the country is clearly world class when it comes to clinical techniques. “The nation’s fast development was possible because learning techniques requires only the ability to imitate,” he said. “Today, Korea is on the highest level of imitation and now needs to grow into an innovator.” To do so, the country should be able to design and conduct original, prospective cohort studies on its own people,” Oh said. “Until then, Korea will remain as a follower.” Over the past few decades, Korea has established a foundation of medical knowledge, but using data collected from other countries. In addition, most studies conducted in the country are retrospective, that is, they look at medical events from the past to the present in order to find how they occurred and developed. However, Oh noted, significant scientific value are created by prospective studies, which follows over time a group of individuals who are similar but who differ with respect to certain factors in order to determine how these factors affect rates of a certain outcome. Global medical powerhouses such as the United States and Japan lead innovation in the industry with their prospective studies using original data. Original data help people in different countries create a clearer picture of their health. Over the years, scientists have found that people in different regions show different disease patterns because of genetic and environmental reasons. For example, he said, the rate of problems associated with the extracranial arteries is higher among stroke patients in the United States than those in Korea. “The problem is that prospective studies are expensive, but Korea has certainly reached the stage of needing such an investment if it is serious about growing beyond being a follower,” he said. “The investment won’t bear fruit immediately; perhaps 10 years from now, but it certainly will.”

Stroke: the second biggest killer of Koreans

Stroke is the second leading cause of death among Koreans only after cancer, according to the Ministry of Health and Welfare. The disease, also called a “brain attack,” occurs when blood flow to a part of the brain is cut off, which leads to brain cell death. A brain aneurysm, or a blood vessel rupture or leak (hemorrhagic), and a blood clot blockage (ischemic) are the two main types of stroke. The most common symptom of the disease is sudden weakness or numbness of the face and limbs. A serious stroke can cause paralysis in one or both sides of the body or even death. When Oh began his medical career 30 years ago, stroke was regarded largely as untreatable in Korea, especially when it was associated with cerebral arteries. After becoming a professor at Seoul National University Hospital in 1995, Oh trained at the Stroke Center at the Cleveland Clinic in Ohio, where he learned surgical techniques and research from 1998 to 2000. His focus has been educating neurosurgeons in Korea. Thanks to his efforts, cerebral microanastomosis, a surgical technique that connects blood vessels of the brain, is now commonly used for stroke patients in most Korean hospitals. He also played a vital role in setting up clinical and research systems at SNUBH’s then newly opened center for stroke treatment, the country’s first such center.