On Keeping Up

Medicine, we are taught, is an evidence-based discipline. Throughout our training, we are urged to choose treatments supported by evidence, methods that have been demonstrated, selections grounded in accumulated data. This is the identity of the field — and, at the same time, a safeguard that protects the patient. Yet from a certain distance, one notices a paradox folded into how medicine has arrived at the place it now occupies. For medicine to advance, someone must step first into territory where evidence has not yet been fully assembled. Many of the treatments we now call “standard” began as approaches that lacked evidence, drew criticism, and were sometimes dismissed outright.

On top of that paradox, a quiet question remains: on which side does a surgeon’s current choice fall? Is what I am attempting now an effort in service of medicine’s advancement, or is it the overuse of a treatment whose evidence is not yet sufficient? The boundary between the two is less clear than it first appears. Some days the first reading seems right; other days the second begins to look more honest. If a surgeon ever believes they have fully set this question aside, that is probably the most dangerous state of all.

This tension becomes clearer when one considers how far UBE has come. When UBE was first being introduced, many surgeons of the senior generation — those who had become deeply familiar with microscopic surgery — criticized or opposed the approach, often strongly. Presentations at academic meetings were frequently not taken seriously; at times they were quietly dismissed. Behind that criticism stood the weight of evidence and experience that the senior generation had accumulated over many years, and from where they stood, their reservations had reasons that were valid.

It was during that time that I first learned UBE, under Dr. Heo. He had been part of the technique from its earliest stages. The work consisted of discussing one small detail of a case in the operating room, and afterward sitting down to assemble what we had seen into a paper. Which angle was safer, which sequence was better, which patients this approach was in fact not suited for — the pleasure of stacking these small pieces one by one is a memory I carry clearly. Outside the room, criticism and quiet ridicule had not disappeared. Inside, what continued was the slow, patient work of refining how this could become safer for the patient. Looking back at that period, I think it was a quiet piece of fortune to have been able to learn under him. Each time I now see UBE being accepted around the world, that feeling returns more strongly.

The worldwide acceptance of UBE did not come from argument or conviction. It came through the long accumulation of patient outcomes, gathered one case at a time, assembled into papers, and placed transparently before the field. In the end, this is the only way a new approach can establish its own legitimacy. The response to criticism is not rebuttal but a slow record of patient results, made public with nothing hidden. For a surgeon attempting something new, the work of publishing is therefore not an option but a way of taking responsibility for the approach to the end.

What that experience left with me is not simply confidence in UBE as a technique. What stays longer is a sense that what we now call “standard” is not permanent. Many things that were considered standard ten years ago have already shifted elsewhere, and some of what counts as standard today will look different a decade from now. Because medical technique never stops moving, a surgeon who keeps practicing only by habit may not harm their patient directly, but drifts quietly, bit by bit, away from what the best option would be today. What that drift means for patients takes a long time to become visible.

What, then, does “continuing to study” concretely mean? In the busy rhythm of clinical work, that phrase too easily passes as rhetoric. Written out more plainly, it means something like this. Reading the literature steadily. Knowing not only what is being debated within one’s own narrow area but what questions are being asked in the adjacent fields. Looking at how other centers abroad, not only domestically, are approaching the same problem. And — the hardest of these, and perhaps the most important — recording one’s own results honestly and returning to them. Not only the good results, but the results that turned out worse than expected. All of this takes time. And that time, no one gives on your behalf.

There is another kind of humility required here. The process of learning something new does not always lead forward. Sometimes a new approach one has invested in turns out, in the end, to be no better than the earlier standard — or worse. The ability to step back honestly when that becomes clear, to acknowledge the limits of a method one once advocated for, is also part of what it means to study. Studying is not only the capacity to take in what is new. It also includes the capacity to reopen one’s own earlier choices.

A question remains: how does all of this eventually reach the patient? Patients do not know which paper we read last week, which surgical video we studied yesterday. But they feel it in another way. The patient who is walked through more options for their condition; the patient who is given an explanation that helps them avoid a method that is not right for them; the patient who, when necessary, is referred elsewhere. Beneath all of these experiences is the quiet fact that the person seated across from them knows what the best option today is. The patient may not identify this explicitly, but it is what they ultimately receive.

For this reason I think of studying not as a personal virtue but as a condition built into the seat itself. The moment a surgeon takes that seat, a quiet demand already sits there alongside them: that they know what the best option today would be. The difference between a surgeon who takes that demand seriously and one who stays within the comfort of a familiar method is barely visible in any given visit. But over a decade, that difference accumulates — in the outcomes of the patients they treat, and in what they pass to the next generation.

So I try to accept, willingly, that this work is an assignment that does not end. There is no point at which one can say, “This is enough now.” That there is no such point may be, I think, both the hardest thing about this profession and the most honorable thing about it.