Columbia University Division of Urology, Mount Sinai Medical Center, Miami Beach, Florida, USA.
Acad Med. 2010 May;85(5):863-8. doi: 10.1097/ACM.0b013e3181d73a45.
To investigate the effects of fellowship training on a surgeon's learning curve for cancer control after open radical prostatectomy.
The study cohort included 7,765 prostate cancer patients who underwent radical prostatectomy performed by 1 of 72 surgeons at four major U.S. academic medical centers between 1987 and 2003. Multivariable models were used to determine the learning curves for biochemical recurrence and surgical margins, separately for surgeons with and without fellowship training, after adjustment for standard prognostic variables.
Initial results for fellowship- and non-fellowship-trained surgeons were similar (five-year probability of recurrence for first case: 19.4% and 18.3%, respectively; absolute difference: -1.1%; 95% confidence interval [CI]: -5.5%, 3.0%; P = .7). However, the rate of learning was faster among fellowship-trained surgeons (P = .006), which resulted in their overall superior cancer control (P = .001; difference: 4.7%; 95% CI: 2.6%, 7.4%). With regard to positive surgical margin rates, fellowship-trained surgeons initially had superior results than did non-fellowship-trained surgeons (P = .005; 36% versus 42%; absolute difference: 6%; 95% CI: 1%, 10%), but the difference between the groups' subsequent learning curves was not significant (P = .9 for interaction).
The learning curve for biochemical recurrence depends on surgical training, whereas the learning curve for surgical margins does not. This difference suggests that improvements in margin rates result from reflection on specific aspects of surgical procedure, whereas improvements in biochemical recurrence occur by some general process of improvement in surgical technique. Further research into the mechanisms of surgical learning is warranted.
研究住院医师培训对开放根治性前列腺切除术后癌症控制的外科医生学习曲线的影响。
研究队列包括 1987 年至 2003 年间在四家美国主要学术医疗中心由 72 名外科医生中的 1 名进行的 7765 例前列腺癌患者。使用多变量模型，分别针对具有和不具有住院医师培训的外科医生，在校正标准预后变量后，确定生化复发和手术切缘的学习曲线。
接受和未接受住院医师培训的外科医生的初始结果相似（首例五年复发率：分别为 19.4%和 18.3%；绝对差值：-1.1%；95%置信区间[CI]：-5.5%，3.0%；P =.7）。然而，接受住院医师培训的外科医生的学习速度更快（P =.006），这导致他们整体上的癌症控制效果更好（P =.001；差值：4.7%；95%CI：2.6%，7.4%）。就阳性手术切缘率而言，接受住院医师培训的外科医生的初始结果优于未接受住院医师培训的外科医生（P =.005；36%对 42%；绝对差值：6%；95%CI：1%，10%），但两组后续学习曲线之间的差异无统计学意义（P =.9 用于交互作用）。
生化复发的学习曲线取决于手术培训，而手术切缘的学习曲线则不然。这种差异表明，切缘率的提高是由于对手术过程的具体方面进行了反思，而生化复发的改善则是通过某种外科技术改进的一般过程发生的。需要进一步研究手术学习的机制。
