European Journal of Neurology 2010, 17: 522523
EDITORIAL
The silent gap between epilepsy surgery evaluations and clinical
practice guidelines
Epilepsy impacts 0.51.0% of the worlds population
[1]. Despite a plethora of therapeutic options for med-
ical management of epilepsy, anywhere from 15% to
40% of all patients with epilepsy fail to respond [2]. For
such patients, epilepsy surgery should become an
obvious choice for treatment. Epilepsy surgery has been
evaluated extensively by a number of studies and has
been shown to be benecial and superior to medical
management in patients who are appropriate candi-
dates for operations [2,3].
In 2003, the Quality Standards Subcommittee of the
American Academy of Neurology performed a system-
atic review of the ecacy and safety of anterior tem-
poral lobe resections nding that anterior temporal lobe
resection reduced the occurrence of disabling seizures
and improved patients quality of life with infrequent
morbidity and could reduce the risk of long-term mor-
tality [4,5]. Other public health organizations have also
published similar ndings For example, The Swedish
government introduced ocial recommendations on the
management of epilepsy stating that patients with severe
partial epilepsy not responding adequately to medical
treatment should be evaluated for epilepsy surgery [6,7].
The question that arises, however, is how well are these
guidelines implemented in identifying appropriate can-
didates for curative epilepsy surgery?
In this months European Journal of Neurology, Dr de
Flon and colleagues from the Uppsala University
Hospital Epilepsy Center in Uppsala, Sweden, quantify
the utilization of epilepsy surgery evaluations in patients
who are appropriate for referral, which begins to measure
the gap between clinical practice and refractory epilepsy
guideline implementation [8]. The authors creatively
evaluated the prevalence of referred and non-referred
epilepsy patients during the years of 19982002 to assess
the extent that non-referred patients should have been
referred if all physicians were following national recom-
mendations for presurgical evaluation for epilepsy.
Of 48 patients, 28 (58%) potential surgical candidates
were inappropriately not referred for surgery. In the
patients who were not considered for referral, 45% of
EEG and 33% of neuroradiologic ndings were lacking
despite Swedish guidelines that explicitly state that
EEG and neuroradiology evaluations are standard of
care for epilepsy management. Furthermore, IQ was a
barrier to epilepsy surgery with mental retardation cited
as a bias against a surgical evaluation.
This is the rst study of its kind to show how a public
health system with well-established clinical guidelines
522
doi:10.1111/j.1468-1331.2009.02892.
for investigation, diagnosis, and therapy of epilepsy
impacts the appropriate identication of patients for
appropriate care. This investigation conrms what many
physicians in the epilepsy community have known for
some time: there is room for improvement in recognizing
epilepsy patients who may benet from surgery. Indeed,
the analysis shows that a signicant percentage of
refractory epilepsy patients are not evaluated for surgery
despite the abundance of evidence demonstrating the
superiority of surgery in curing epilepsy.
It is dicult to understand why physicians remain
reluctant to choose surgical treatment for epilepsy.
There are three potential explanations for this gap. One
possibility is that physicians are not fully aware of the
existing guidelines. Thus, more work is needed to dis-
seminate clinical guidelines at the point of patient care.
Technology and electronic records could facilitate such
an endeavor. Another explanation is an inherent phy-
sician bias against brain surgery. Neurosurgery, par-
ticularly brain surgery, often carries a stigma, and there
are concerns about cognitive and behavioral adverse
eects related to epilepsy surgery. We must convey the
consequences of intractable epilepsy and the signicant
toll it places on patients and healthcare systems and
that the benets of surgery clearly outweigh the risks.
Lastly, physicians may fail to translate clinical guide-
lines into practice at the point of care as a result of
unconscious unspecied biases.
This study conrms the existence of a gap between
physician knowledge and their actions collectively
known as a lack of mindful practice [9]. The concept is
that tacit knowledge typically learned from papers,
guidelines, and other type of didactic materials are
inuenced by observation, practice, prior experiences,
beliefs, and deeply held values. An individual physician
has to be aware of oneself with regard to how best to
not allow particular personal biases to interfere with the
decision-making process with regard to patients. Phy-
sicians constantly make moment-to-moment value-
laden decisions that entail cognitive and emotional
factors. Self-knowledge is essential to the expression of
core values in medicine, and one must be able to
understand that sometimes emotional perceptions and
biases may cloud the decision process on a one-on-one
basis with individual patients.
So what should the next step be in increasing
appropriate epilepsy surgery evaluations? Perhaps, we
need to better evaluate the physicians decision-making
process as it pertains to translating clinical guidelines at
2009 The Author(s)
Journal compilation 2009 EFNS

the point of care. Newly instituted performance in
practice modules in which self-evaluation of patients
charts are performed by physicians in establishing
quality care gaps may help to alleviate the situation as
part of maintenance of certication. It is only through
the individual physicians self-awareness of their prac-
tice habits that neurologists can make decisions that can
make a dierence in providing the best care for our
patients with epilepsy.
J. I. Sirven
Division of Epilepsy, Department of Neurology, College of
Medicine, Mayo Clinic, Mayo Clinic Arizona, Phoenix, Arizona
(e-mail: sirven.joseph@mayo.edu)
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