The Learning Curve and the Practicing Surgeon: Integrating a New Skill/Procedure into Your Practice

John J. Murnaghan, M.D., MSc, MA, FRCSC
Chair, COA's Continuing Professional Development (CPD) Committee
Holland Orthopaedic and Arthritic Centre
University of Toronto
Toronto, ON

Carol Hutchison, BSc, M.D., MEd, FRCSC, CYT
Associate Professor, University of Calgary,
Calgary, AB

Guy Moreau, M.D., FRCSC, LL. L. LL. B.
Ottawa, ON

Wade Gofton, M.D., FRCSC
Ottawa, ON

Introduction

For those of us in practice for more than ten years, it is very clear how many new products and new surgical techniques are available today. How many of us were routinely using locking plates or considering hip resurfacing ten years ago? In order to introduce a new surgical procedure to our practice, we have to learn the technique and then implement it in practice responsibly. We decided to explore the theoretical concept of a learning curve and illustrate some of the considerations with a real-life experience. In addition, there is a related issue of how to inform patients who may be having the procedure during the introduction phase and how to frame the discussion to protect the patient, the surgeon and the institution. I asked Wade Gofton (Ottawa) to introduce the concept of the learning curve and Carol Hutchison (Calgary) to illustrate some of the challenges and pitfalls she encountered with the 2-incision hip experience. Guy Moreau (Ottawa) gave an administrative and legal perspective on how to handle the introduction of new techniques. Each of these surgeons shared their perspectives and contributed to an interesting discussion.

 

The Learning Curve
There are a rapidly increasing number of articles in our literature reporting on the learning curve of a particular surgical procedure or technique. Defining a learning curve for a specific procedure is a difficult task because learning can't be directly measured, but inferred by a relatively permanent change in performance over time. The literature documents higher complication rates and decreased OR efficiency in the early stages which should change with experience. There is fairly clear consensus that a positive correlation exists between the number of surgical procedures performed by a practitioner and patient outcomes1,2. It is also recognized that many complex new procedures are associated with a learning curve. With increasing experience, operative time decreases, the complication rate is lowered3-8 and there are fewer conversions to the standard procedure3,7,8.

There are three main features of a learning curve: 1) the initial starting point identifies where the performance of an individual surgeon begins, 2) the rate of learning measures how quickly the surgeon will reach a certain level of performance and 3) the asymptote or expert level measures where the surgeons performance stabilizes9,10 (See Figure 1). The initial curve may be relatively flat until an understanding of the concepts and available information is understood. The curve then falls rapidly with early experience11,12 and plateaus as performance is optimized. Discussions about learning curves can be further complicated by descriptions of its form. Complex or problematic procedures are often defined as having a steep learning curve. However, a learning curve with a steep slope implies large gains in proficiency over a few cases (or time) suggesting that the procedure is quickly learned and thus ideal with respect to the number of patients that may be exposed to risk. The more complex the procedure, the more gradual the learning curve.

JM_Figure1

Figure 1: Learning Curve. With increasing case number (experience) complications and OR times per case generally decrease. The presence of a preceptor can force the learning curve to be steeper by providing technical tips and feedback (increasing the available information for learning) while protecting the patient from complications during the early learning phase.

A surgeon reviewing learning curve articles must understand that learning curves are specific to an individual. The shape of their learning curve is affected by individual's experience, motivation, tools and health care team available to them. For the individual surgeon that is considering incorporating a new technique into their practice, it is important for them to understand what the reported "learning curve" might mean to them and how it may impact their outcomes. They must also consider what tools are available to them to minimize the impact of a learning curve on their patient's outcomes.

Practical Tips and a Learning Contract
The recent history of orthopaedics is riddled with examples of how great procedures get a bad name simply because the importance of effective and adequate education has been overlooked in the plan for dissemination. Education may be revisited after the fact, but more often than not, the procedure is abandoned. Surgeons and Industry have the same goal: safe and effective introduction of new technologies. Industry usually has a tighter timeline. Learning any new technique to the expert level requires time and dedication. The amount of time is usually underestimated. There are several steps worth taking to achieve expertise:

  1. Take your time
  2. Create a Learning Contract
  3. Find a partner / coach
  4. Practice, Practice, Practice
  5. Patient selection
  6. Lower your stress
  7. Evaluate
  8. Start teaching others

Start with a learning contract with yourself, stating your goal. The learning contract includes your timeline, the steps you will take to learn the technique and who you will engage to assist you with this task. There are numerous educational advantages to approaching a new technique using different learning modalities. The more modalities you implement, the greater the depth of your learning. Some examples of modalities include: 1) review the literature, 2) discuss with colleagues, 3) watch DVD, 4) review written surgical technique (if one exists) or write your own, 5) attend a course, 6) practice on Sawbones©, 7) visit one or two experts, 8) mental practice or visualization, 9) practice on cadavers, 10) repeat any of the above. We are all aware that these modalities are available to us, but we rarely employ them in an organized step-wise fashion with clear goals. Finding a surgical assistant, partner or coach to complete the learning with you will optimize implementation and lower your stress. Be very clear about patient selection at the outset, so that this does not compromise your learning. There will be time once greater experience is gained to expand patient selection criteria if appropriate. To minimize distraction, it is ideal to book new techniques as the first procedure of the day. Rather than planning several back to back, leave a few days to evaluate technical issues or changes you would make to improve the execution. Evaluating error is a tremendous learning opportunity. Errors can be powerful lessons as long as the same one never occurs twice (then it is a curse). There is no better way to gain expertise than by teaching others. In order to teach others, you must be able to articulate exactly what you are doing and why. You must be able to anticipate errors that can happen, how to avoid them and what you will do to correct them. By teaching, you will be interacting with others who are focused on the new technique. This will add to your wisdom and skill.

Administrative Considerations
Most of the time, the new procedure will be a variation of what the surgeon is already doing. However, when we are dealing with a completely new technique or procedure, the surgeon and the hospital/institution must assure patient well-being and safety. Documenting the steps that you, the surgeon, have undertaken to develop expertise in the form of a learning contract will aid with hospital privileges and assurance to licensing bodies.

The review and approval by a Research and Ethics Board is a safeguard for procedures undertaken within a research project. For new technologies and procedures not covered by a Research and Ethics Board, the surgeon must be able to provide evidence of education and experience. This is a pre-requisite of our licensing body that a physician "may practice only in the area of medicine in which this physician is educated and experienced"13.

Additionally, it is important to confirm that any new procedure is included within the surgeon's hospital privileges and that the patient is well aware of this new technology or procedure through an informed consent. The essential elements of informed consent are: the nature of the treatment, the expected benefits, the material risks, the material side effects, the alternative courses of action and the likely consequences of not having the treatment14,15. The acceptance of the new technique and procedure by our peers through national16 and/or provincial associations is of upmost importance since its members will be called upon to provide their professional opinion in case of litigation.

References

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  2. Katz J.N., Losina E., Barrett J., et al. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am 2001;83-A:1622-9.
  3. Meehan J.J., Georgeson K.E. The learning curve associated with laparoscopic antireflux surgery in infants and children. J Pediatr Surg 1997;32:426-9.
  4. Kreder H.J., Deyo R.A., Koepsell T., Swiontkowski M.F., Kreuter W. Relationship between the volume of total hip replacements performed by providers and the rates of postoperative complications in the state of Washington. J Bone Joint Surg Am 1997;79:485-94.
  5. Nunley R.M., Zhu J., Brooks P.J., et al. The learning curve for adopting hip resurfacing among hip specialists. Clin Orthop Relat Res 2010;468:382-91.
  6. Watson D.I., Baigrie R.J., Jamieson G.G. A learning curve for laparoscopic fundoplication. Definable, avoidable, or a waste of time? Ann Surg 1996;224:198-203.
  7. Cagir B., Rangraj M., Maffuci L., Herz B.L. The learning curve for laparoscopic cholecystectomy. J Laparoendosc Surg 1994;4:419-27.
  8. Soot S.J., Eshraghi N., Farahmand M., Sheppard B.C., Deveney C.W. Transition from open to laparoscopic fundoplication: the learning curve. Arch Surg 1999;134:278-81; discussion 82.
  9. Cook J.A., Fayers P. Statistical evaluation of learning effect in surgical trials. Clinical Trials 2004;1:421-7.
  10. Raja R. The impact of the learning curve in laproscopic surgery. World Journal of Laproscopic Surgery;1:56-9.
  11. Lane N. Skill Acquisition Rates and Patterns. Issues and Training Implications. New York: Springer-Verlag; 1987.
  12. Ohlsson S. Learning from performance errors. Psychol Rev 1996;103:241-6.
  13. College of Physicians and Surgeons of Ontario Guidelines. CPSO Website www.cpso.on.ca
  14. Consent to Medical Treatment: Health Care Consent Act, 1996, SO 1996, C2, Scha
  15. Consent A Guide for Canadian Physicians, 4th Edition, The Canadian Medical Protective Association
    1. CPSO, Consent to Medical Treatment, Policy # 4-05
    2. A Guide to the Health Care Consent Act, CPSO, 1996
  16. The Courts and Informed Consent: Reibl V Hughes, 1980 CanLII 23 (SCC)
    1. Hopp V. Lepp, 198 CanLII 14 (SCC)
    2. Archibald V. Kuntz, 1994 CanLII 535 (BC SC).
  17. Objectives of Training in the Specialty of Orthopedic Surgery, Royal College of Physicians and Surgeons of Canada, RCPSC Website www. royalcollege.ca

 

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