Open colectomy (OC), is a surgical procedure in which part of the colon (large intestine) is removed through a large abdominal incision. It is by anyone’s standards a ‘big operation.’ Twenty years ago, a generation of surgeons, it was the standard of care, 97% of surgery of the colon was performed that way. In the space of that surgical generation the technique of minimally invasive colectomy (MIC), removing a portion of the large intestine using multiple small incisions and a scope, went from a curiosity to the operative choice for 59.3% of cases in the US. Surgeons already in practice had to learn this new technique, surgeons in training had varying degrees of exposure as MIC moved into the mainstream of care and enough faculty became proficient to enable training surgical residents. Can you teach an old dog a new trick?
The study, Surgeon Variation in Complications With Minimally Invasive and Open Colectomy by Mark Healey et. al. in JAMA Surgery looked at both techniques and begins to look at that question. Using 5196 patients, undergoing surgery with 97 surgeons judged proficient in both techniques that looked at complication rates for each procedure. MIC was associated with statistically fewer complications than OC; by most measures patients undergoing MIC were healthier and had elective rather than urgent or emergent surgery. We know the patients and technique varied, but the focus was not on the procedure, it was on the surgeons. Here are the key findings:
- Surgeons performing MIC showed a 3-fold variation in the adjusted complication rate ranging from 8.8% to 25.9%
- Surgeons performing OC had less variation in their adjusted complication rates, the best had rates of 25.9, the worst 43.8%
- The ‘best’ surgeons for MIC were not the best for OC and vice versa. The mean change in ranking of the surgeons for complications was 25 positions out of 97
Previous study had suggested that about 18% of the variation in complications are attributable to the hospital and 30% to the surgeon. This study explores that 30% and shows that MIC and OC are operations requiring different skill sets, and by skill, I am referring to both technical abilities and clinical judgment. The authors suggest that the findings may indicate that the surgeons most proficient in OC, had less experience in MIC, during training, because MIC was not an established technique or trained during the transition from OC to MIC and their mentors felt uncomfortable doing MIC and found reasons why it was ‘not indicated.’ While the authors did not have access to each surgeons' age and training I would argue that age was a significant variable, these surgeons proficient in OC and not so much in MIC were older dogs.
The best way to train surgeons in new techniques, as well as the best place for that training, remain unknown. Proficiency is incompletely measured by written examination; physical skills, perception, judgment are critical factors that do not yield so readily to standardized, objective measurement. When a surgeon completes training and joins a hospital staff, their proficiency is certified by satisfactorily completing a surgical residency. Hospitals may require an observation period of a number of cases or a few months, but ability is poorly assessed within those timeframes. Removing a surgeon’s privileges at that point is a complicated and legally entangling procedure - it rarely happens. So how do you teach those old dogs? Frequently expertise is purchased, you bring a surgeon conversant with the new techniques into the group. They can provide the necessary skills for the practice and help mentor their partners. Training is often offered through short (measured in days) training course with hands-on experience or simulations. But is that course certificate a real measure of proficiency? Hospitals, because they ‘give privileges’ to surgeons to perform different operations are asked to make that judgment and are ill-equipped to do so. It remains a difficult problem. I would add that this old dog problem is equally true for my colleagues in medicine, it is just harder to identify.