Does skill level plateau?

There have been studies done showing a plateau at 250. I cannot cite them, it was shown to me at a consultation bewitch a surgeon I was considering, (who had done over 2000)

Personally I would (and did) ignore that study, and look for a surgeon who had as many thousands of surgeries as possible, with a solid, published track record .

I'm just curious, what brought you to ask that question, since you had the surgery 2 + years ago

Prato,

Big Mac said his surgeon a doctor Patel had done 7000 plus procedures. I don't think number of procedures are a good yardstick for competency.

I did some research in my 4 weeks prior to my RRP and found a Sydney surgeon www.phillipstricker.com.au/as-a-doctor/evidence-based-results/robotic-surgery who published his outcomes.

I'm in Melbourne, so I enquired and found surgeons with comparative stats. As a G9'ner I'm traveling ok so far, and is still happy with my choice of surgeon.

.

Simply put, if you are a newcomer surgeon, how do you get to the high number of surgeries to be considered proficient if everybody goes to the more experienced surgeons? Likewise, when the older surgeons with the experience you want decide to call it quits and retire, where do you go to find a surgeon with the experience you want? I'm not trying to be a wise guy but newcomers have to get experience somehow and the old guys won't be around forever.

Inspector 13 said...
Simply put, if you are a newcomer surgeon, how do you get to the high number of surgeries to be considered proficient if everybody goes to the more experienced surgeons? Likewise, when the older surgeons with the experience you want decide to call it quits and retire, where do you go to find a surgeon with the experience you want? I'm not trying to be a wise guy but newcomers have to get experience somehow and the old guys won't be around forever.

Inspector, I've posed the same philosophical question. I also know what my local urologist told me: He has several thousand open surgeries under his belt, and is well regarded. When Davinci came out, he looked into it, and went to some seminars. He learned two things: First, he learned that even as an experienced open surgeon, the minimum to get competent at Davinci was 250...and he didn't want to risk his reputation with several hundred failures. Second, he learned how much the system cost to buy and set up, and he knew he'd never convince the local 150 bed hospital to buy it and build a team to run it.

I also know that my surgeon introduced me to at least 3 different surgical residents and one surgical fellow. I wonder if they build Davinci robots with dual controls for training?

I have seen a surgery time for Dr Patel of around 1 hour 40 minutes for a couple of RALPs on the forums. A typical time is closer to 2 hours and 20 or more. Just a guess but a very high number of surgeries may result in shorter times.

Atul Gawande describes in Complications (or is it Better ?) some of how surgical training goes. Residents do many procedures, and necessarily make some mistakes, are initially less precise, while working under the tutelage of an experienced surgeon. He describes his own mistakes and embarrassment as well as the learning curves of others. The attending will observe, and insist the resident try again. So at least at a teaching hospital, and perhaps especially so with a senior, respected surgeon, there is a fair chance a procedure is largely performed by a resident without the patient ever knowing. I wouldn't be surprised if the chief resident who introduced herself prior to my RP in fact did most of the cutting, clamping, cauterizing, suturing under the attending's watchful eye. Pretty much true that it must be so if we're to have successive generations of skilled surgeons.

Dr. Gawande also reports that hospital insiders routinely assure that their own family members are not operated on by residents - sometimes insist residents not be allowed in the OR.

I've been told by surgeons that the Da Vinci procedure is very different from the open one - skill at one has no transfer to the other. Makes sense when I watch videos of the two procedures.

We are dealing with several different factors, at least some of which we can not account for. I am basing this opinion on 36 years experience observing surgeons from their 1st day in training who were being trained at least sometimes by those with vast experience.

Abstract on my study N1(me observing) so you won't have to read all that follows: Some will plateau at several hundred and be very good. Most will continue to improve over several thousand and be great. Some will plateau at a couple of hundred and never be really good no matter how many thousand they do.

There is no doubt that increasing experience increases skill, but the question is does this plateau. Yes it does, but 250 might just be a drop in the bucket. Or at the very least, there might be a way to go yet. I don't play golf, maybe some of you do? If so, and maybe you started as a young man playing say several times a week, if by the time you had hit 250 golfballs at say age 18, do you think that you could never get any better than that after another 5 or 10 years of hitting golf balls? Maybe thousands more hit at practice at the driving range? True, you might not ever become great, but there's a good chance you would get a lot better.

I gave the anesthesia for these surgeons, as a CRNA. Probably somewhere between 20,000-30,000+ over that 36 years. There were technical skills to be learned and practiced for us anesthesia types as well. In the early 80s, epidurals for childbirth started becoming readily available. It turned out I seemed to have a knack for that particular technical skill. So I was chosen, along with 2 other guys out of about 15 that had been rotating through the epidural service, to specialize in that. At the end of that 1st year, I had done about 500 epidurals myself. I was way better than at the start of that year and figured I was about as good as anyone could be. Many obstetrical nurses and obstetricians told me that I was very, very good. The nurses often chose me to do their personal epidurals when they had babies.

But, as the years rolled by, I found that I could indeed get better. Quite a bit better, actually. I maybe more or less plateaued at 3 or 4K epidurals, and did not get much better after that even as I got to between 5-10K. I got very rusty on some other skills, but boy could I do a working epidural blindfolded.

But one of those other factors I mentioned in the 1st paragraph is natural ability. I mentioned earlier that I was chosen to be one of 3 to start doing epidurals full time. Prior to that, all 15 of the CRNAs rotated through OB/L+D call doing the epidurals on that day. None of us were very experienced at that time, because epidurals were a new thing. Our bosses, the MD anesthesiologists, had maybe done two or three each doing their residencies. Basically, they showed us how to do one. Then we did one with them watching. Then we went on call. It's not quite as bad as it sounds, because we had all already been doing spinal's for quite a while, which is a similar technical skill. But as far as doing epidurals, it was sort of a case of the blind leading the blind. Then we would rotate through call, getting to practice our new skill, maybe once a month. If it was real busy, you might do 10 or 15 that day, if it was slow you might do none. So depending upon how your luck ran, you might not ever really get a lot of practice at this highly technical skill. After about a year of that, the obstetricians started asking them to set three of us aside to be the only ones that were doing epidurals. Apparently because things went really well when we were on, and could be helter-skelter when others were on duty. Plus, with only being on duty once a month, some of us were not getting the practice we needed to really become good.

The point I'm trying to make is: some people just naturally seem to have a knack for doing certain things. Other people seem to be terrible at those same things, even though they might be great at something else. Don't all of us seem to have certain things that just come easy to us? And other things that just seem really difficult? Can you think of anything that you were just really bad at doing? If you can, there's a good chance that no matter how much you practice it, though you might get much better compared to awful, you'll never be really good at it. Fortunately, there's probably also something else that you just seem to be naturally good at. If so, it probably won't take all that much practice until you're really, really good at it.

Well I can tell you that surgery(And anesthesia for that matter) is no different. Some people are born to do certain surgeries, and some people shouldn't have ever chosen surgery as a career. That does not mean they won't make it through the residency, and end up being a board-certified surgeon. But even if these people do 10,000 surgeries, they may not ever be as good as the other guy was only done 300. They might be okay, and they might be safe, but they're never going to be really good compared to some other guys. And you and I normally have no way of knowing who these good surgeons are. The only ones who have a chance of knowing are the ones who work in surgery with them. And believe me, they know. They know who the good surgeons and the good anesthesia providers are, at least as far as things going smoothly during surgery go (But even they can't really know how the patient does afterwards can they?). They're not likely to make it public, but if you talk to any of them it will be: " Oh so-and-so is doing my surgery/anesthesia, but the other so-and-so is never going to touch me". Also, speaking more to my area of expertise, I can tell you that as we got busier and had to hire some more people to do the epidurals, that the people naturally skilled in epidurals were not always the ones available to us. Some of them were competent at best. No matter how many years they spent doing epidurals or how many hundreds they did, they never became some one a labor and delivery nurse would ask to do their or their daughters epidural. They did improve, and they were competent, but they never got really good. They just didn't have the natural ability, or the knack for it. From what I have observed, it is the same with surgeons or pretty much most areas of life. Practice definitely improves things, but it does not always make perfect.

One final thing. When it comes to those positive margins, and judging a surgeons ability based on that? Just consider this possibility: if the surgeon becomes vastly experienced, becomes the head of the major institution, it's quite likely that some of the worst patients will be referred to that surgeon. Patients with increased odds of a poor outcome. Just one more thing to consider.

Post Edited (BillyBob@388) : 5/10/2015 2:50:32 PM (GMT-6)

Philosophically, I agree that there is a need to train the younger surgeons and get them the experience they need to become competent. It's very important for the "greater good"

Unfortunately, when I, or most anyone here, I'm guessing, as an individual, is on the table, the greater good, doesn't really matter much.

Common sense tells me that smart people learn from their mistakes, which leads me to believe that I'm better off with a surgeon that's down 7000 of these, than one that's done 500 or 1000. I don't really need a study to convince myself of that