Angela Spang, Head of Research at London Medical Education Academy (LMEDAC), discusses how to approach the many learning curves in modern surgery
Up until the last decade, surgeons learnt each new procedure from their mentor, and proceeded to carry out that same procedure for the rest of their career.
The results may not have been as good as one would want, with limitations in infection control, follow up and even basic surgical skills. However, there was one big benefit to this approach – and this may have even saved lives: each surgeon went through only a few learning curves.
Learning curves in modern surgery
When you compare the number of new products and procedures that a surgeon has to learn today to just ten years ago, it is clear that there is a huge difference. Innovations in spine surgery are coming thick and fast, and the internet ensures that new ways of carrying out procedures are shared between surgeons, hospitals and countries within seconds. Unfortunately, that means learning curves are more common and need to happen quickly. The way these learning curves take place are on live patients and in some cases, patients get hurt.
Very few articles looking at different MIS spine procedures assess learning curves and those that do give conflicting advice. One study reported no learning curve for open vs. MIS discectomy/laminotomy, which sounds strange as another study indicated that 20–30 cases were required for a surgeon to become proficient in performing a variety of MIS spine fusions (such as cervical MIS fusions, MIS anterior lumbar interbody fusions (ALIF), MIS transforaminal lumbar interbody fusions (TLIF), and MIS pedicle/screw placement in the thoracic/lumbar spine). Several other studies specifically cited that to become proficient in the performance of TLIF surgeons need to perform between 10 to 32, to 40, to 44 such cases .
Learning curves exist but they are not well enough defined for each new procedure or product, and because of this they can cause injury to our patients.
See one, do one, teach one
Doctors train their registrars, and at some point the young ones have to make the first cut. He/she may be skilled, experienced, have good hand-eye coordination, be confident and know their anatomy. Or not.
Luckily, the models and simulation training have become better: there are brilliant tools that can mimic real life. But they are just that. Simulations. They cannot be compared to real human tissue, real bone, real nerves.
The majority of training today still takes place on live, usually unknowing patients. Data in all surgical and interventional areas confirm that learning curves cause injuries to patients. In spine surgery, adverse events are often life-changing.
The generous, brave alternatives are body donors for human tissue dissection in spine procedures.
In order to improve a surgeon’s learning curve and reduce their chance of an adverse event, the London Medical Education Academy (LMEDAC) offer courses that provide the closest possible real-life training environment, using fresh-frozen cadavers. Courses are possible because of the very generous donation from donors. Organ and body donations are two different things, and if you have signed up for one, it doesn’t mean you have automatically signed up for the other. The Human Tissue Authority has the responsibility of managing the process in the UK: www.hta.gov.uk/faqs/body-donation-faqs
Unfortunately, there are two problems:
Not all bodies can be accepted (there are certain criteria) and
The number of donations are way too few
Today, it is possible to import tissue from other countries to be able to meet the demand. The supply is mostly from the US, which has a strict donation, storage and transport process that meets the UK’s requirements in terms of ethical Standard Operating Procedure (SOP) and legal restrictions.
Many different procedures, and most have an available spine
LMEDAC run courses in many different disciplines and in some instances, this involves dividing the donation to optimise the wish of the donor: to train doctors to be better surgeons. LMEDAC aim to always ensure burial is done as a complete body (this does not always happen otherwise). The respect and gratitude for the donors is immense, and courses always start with a silent moment to thank those who have generously donated themselves to improve the outcomes for those who are still here.
Often when there is training on other areas, the spine is kept intact. It is then possible to offer attendees the opportunity to train on several donors to compare techniques or medical devices. With several locations across the country, lab time is optimised providing hands-on training instead of spending precious hours on trains or in the car.
How often should you train to keep your learning curve up to date?
LMEDAC recommend once every two years, and every time you go through a new learning curve (procedure or product).
This ensures that if the worse should happen and you have a serious complication, you will be better equipped to deal with it in a safe manner. Furthermore, if and should someone question your skills, you can prove that you have trained before you operated on a patient.
- Nancy E. Epstein, Learning curves for minimally invasive spine surgeries: Are they worth it? Surgery Neurology International, 2017; 8: 61.
- Dr Paul Goldsmith. The Medico-Legal Crisis and How to Solve It. Centre for Policy Studies, October 2017.