The learning curve is an actual topic that is commonly assessed in congresses and discussed among the medical community. It has been used without a straight and clear definition to justify some surgeons' interests. Under the idea of "doing more and more of just one procedure is doing better", some surgeons promoted the centralization of procedures and the almost criminalization of the surgeon who can do it but is an outsider.
The centralization of procedures can have a negative impact. Patients living in remote locations will not have the same opportunities and accessibility to the best treatment. These patients will have to travel and eventually sacrifice near family support to get treated. Psychologically this will harm the patient's recovery. Additionally, centralization will preclude these patients to have a possible complication treated in a nearby hospital following discharge home. Doctors working in a remote hospital will not be able nor want to deal with complications from a procedure they are not allowed to do. Doctors cannot defend that only a few surgeons should perform a particular procedure while defending that all surgeons must know how to treat complications from it. It is non-sense but is reality. (Read the following post for more information about the consequences of centralization for patients and doctors: "Centralização, volume e especialização dos cirurgiões. O caminho será o correcto?")
(I am excluding from this idea those procedures that are extremely rare and in the need of a complex multidisciplinary process that unfortunately cannot be available in all hospitals.)
This administrative and prohibitive way of collecting more patients and cases is based on the learning curve, and the huge case volume a surgeon must have to know how to safely perform a procedure. Is this correct? Am I better just because I did it more often? The problem lies in not auditing the results. For the last years, the number of procedures has been the only criteria to define both the reference center and the surgeon. Interestingly, studies concluded that whether you perform 11 or 60 pancreatoduodenectomies a year, final outcomes are equal.
The first question is what endpoint to use to assess the completion of the learning curve. We are always learning and improving, so the endpoint is difficult to define. To reach a plateau in operation time keeping a low rate of complications with good outcomes eventually marks the end of the learning curve. Is there a fixed number? I guess not.
Several factors influence the learning curve. Surgeons, patient characteristics, tumor pathology, hospital, equipment, and case volume are all possible factors with an impact on the learning curve. The most important is the surgeon himself, I think. The number of procedures a surgeon must do to complete the learning curve cannot be a fixed number. Different surgeons have different skills, and each one has its own pace. For example, the learning curve for posterior retroperitoneoscopic adrenalectomy is shorter if the surgeon has laparoscopic skills gained in other procedures. Knowing how to perform different laparoscopic procedures, makes it easier and faster to learn how to perform safely and effectively a new one. Case volume will be crucial to keep the pace. Probably, if all surgeons would keep doing different procedures, a lower number of cases would be necessary for those surgeons to learn a specific procedure. In the end, centralization would not be so necessary.
In conclusion, different procedures have different learning curves for different surgeons. Having skills in several procedures will make the learning curve shorter. Once again, do not limit yourself in knowledge. Know your boundaries and skills limitations but try to improve without risking your patients' wellbeing. Learn from the masters before you do. Try to perform different procedures and learn as much as you can from each one. Avoid the comfort of doing just one thing for your entire life. Comfort is the enemy of progress.
References:
Carlos Eduardo Costa Almeida
General Surgeon
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