Retiring the Learning Curve

Abstract

Tom Chalmers was a great American advocate for the power of metaanalyses and the adjudication of doubt through randomized controlled trials. He was famous for his admonition to randomize with the first patient in a trial and for his abhorrence of the learning curve in clinical therapeutics. A scientific icon, Dr. Chalmers was an internist, a gastroenterologist, a NIH researcher, a department head, a medical school dean, and a hospital president. His distaste for the learning curve principle was universal and not limited to surgery. He often stated that if a physician or surgeon believed that his first cohort of patients undergoing a new procedure would have a higher mortality and morbidity than his/her subsequent patients, the doctor was obligated to share that perception with those first patients and to tell them that his care of them will be more filled with hazard than he hopes his subsequent efforts will be. In our current era of disclosure, should not this transparency of information be expected from all physicians and surgeons? The only reasonable alternative to such full disclosure in the practice of bariatric surgery is to retire in principle and, more importantly, in reality, the “learning curve” concept. The paradox of our field is this: On the one hand, bariatric surgery requires rigorous, specialized training and the repetitive practice that begets mastery. On the other hand, there are no techniques to learn that are, in and of themselves, novel. The cutting, dissecting, resecting, sewing, and stapling, as well as the clamping, ligating, and cauterizing or sealing of vessels, lysis of adhesions, and even the insertion of foreign bodies, require the same skills as do other aspects of abdominal surgery. Gaining access to the abdominal cavity laparoscopically or by open surgery is also the same, except that the abdominal wall is thicker in the obese patient. Bariatric operations are, in fact, only the combining of these basic surgical acts to perform a particular procedure. Further, all these basic techniques should be learned and mastered during a 5-year residency. We grant that gaining exposure for bariatric surgery is more difficult, especially in the attic of the abdomen. Obtaining adequate exposure in the obese patient needs to be observed and practiced. There are training programs today in which bariatric surgery is actually used to teach general abdominal surgery and not vice versa. Entering any specialty discipline requires proceeding with caution. After bariatric training, the novice bariatric surgeon should start with patients who are neither super obese nor have extraordinary comorbidities (e.g., patients on a kidney, liver, or heart transplant list), as well as abstaining from revisional surgery until primary bariatric surgery has been mastered. The major complications of bariatric surgery for which the concept of the learning curve has been used as an excuse for suboptimal results include death, leaks, hemorrhage, and postoperative misadventures. Let us consider them in reverse order. Postoperative misadventures, e.g., myocardial infarctions, deep venous thrombosis and pulmonary emboli, out-of-control blood sugar levels, wound infections, pulmonary complications, urinary tract problems, and proOBES SURG (2009) 19:541–542 DOI 10.1007/s11695-009-9833-7