University of Maryland School of Medicine, Baltimore, Maryland.
Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
JAMA Surg. 2020 Jul 1;155(7):607-615. doi: 10.1001/jamasurg.2020.1040.
Learning curves are unavoidable for practicing surgeons when adopting new technologies. However, patient outcomes are worse in the early stages of a learning curve vs after mastery. Therefore, it is critical to find a way to decrease these learning curves without compromising patient safety.
To evaluate the association of mentorship and a formal proficiency-based skills curriculum with the learning curves of 3 generations of surgeons and to determine the association with increased patient safety.
DESIGN, SETTING, AND PARTICIPANTS: All consecutive robotic pancreaticoduodenectomies (RPDs) performed at the University of Pittsburgh Medical Center between 2008 and 2017 were included in this study. Surgeons were split into generations based on their access to mentorship and a proficiency-based skills curriculum. The generations are (1) no mentorship or curriculum, (2) mentorship but no curriculum, and (3) mentorship and curriculum. Univariable and multivariable analyses were used to create risk-adjusted learning curves by surgical generation and to analyze factors associated with operating room time, complications, and fellows completing the full resection. The participants include surgical oncology attending surgeons and fellows who participated in an RPD at University of Pittsburgh Medical Center between 2008 and 2017.
The primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2.
We identified 514 RPDs completed between 2008 and 2017, of which 258 (50.2%) were completed by first-generation surgeons, 151 (29.3%) were completed by the second generation, and 82 (15.9%) were completed by the third generation. There was no statistically significant difference between groups with respect to age (66.3-67.3 years; P = .52) or female sex (n = 34 [41.5%] vs n = 121 [46.9%]; P = .60). There was a significant decrease in ORT (P < .001), from 450.8 minutes for the first-generation surgeons to 348.6 minutes for the third generation. Additionally, across generations, Clavien-Dindo classification higher than grade 2 (n = 74 [28.7%] vs n = 30 [9.9%] vs n = 12 [14.6%]; P = .01), conversion rates (n = 18 [7.0%] vs n = 7 [4.6%] vs n = 0; P = .006), and estimated blood loss (426 mL vs 288.6 mL vs 254.7 mL; P < .001) decreased significantly with subsequent generations. There were no significant differences in postoperative pancreatic fistula.
In this study, ORT, conversion rates, and estimated blood loss decreased across generations without a concomitant rise in adverse patient outcomes. These findings suggest that a proficiency-based curriculum coupled with mentorship allows for the safe introduction of less experienced surgeons to RPD without compromising patient safety.
当采用新技术时，练习外科医生的学习曲线是不可避免的。然而，在学习曲线掌握之后，患者的预后比学习曲线早期更差。因此，找到一种方法来减少这些学习曲线而不影响患者安全是至关重要的。
评估指导和基于熟练程度的技能课程与 3 代外科医生的学习曲线之间的关系，并确定与增加患者安全性的关系。
设计、设置和参与者：本研究纳入了 2008 年至 2017 年间在匹兹堡大学医学中心进行的所有连续机器人胰十二指肠切除术（RPD）。根据他们获得指导和基于熟练程度的技能课程的情况，外科医生分为几代。几代人分别是（1）没有指导或课程，（2）有指导但没有课程，以及（3）有指导和课程。使用单变量和多变量分析来创建按手术代际划分的风险调整学习曲线，并分析与手术室时间、并发症以及研究员完成完整切除相关的因素。参与者包括参加匹兹堡大学医学中心 RPD 的外科肿瘤学主治医生和研究员。
主要结果是手术室时间（ORT）。次要结果是术后胰瘘和 Clavien-Dindo 分级高于 2 级。
我们确定了 2008 年至 2017 年间完成的 514 例 RPD，其中 258 例（50.2%）由第一代外科医生完成，151 例（29.3%）由第二代外科医生完成，82 例（15.9%）由第三代外科医生完成。各组之间在年龄（66.3-67.3 岁；P=0.52）或女性性别（n=34[41.5%]与 n=121[46.9%]；P=0.60）方面没有统计学差异。ORT（P<0.001）显著下降，第一代外科医生的 ORT 为 450.8 分钟，第三代外科医生的 ORT 为 348.6 分钟。此外，随着世代的发展，Clavien-Dindo 分级高于 2 级（n=74[28.7%]与 n=30[9.9%]与 n=12[14.6%]；P=0.01）、转化率（n=18[7.0%]与 n=7[4.6%]与 n=0；P=0.006）和估计出血量（426 mL 与 288.6 mL 与 254.7 mL；P<0.001）均显著降低。术后胰瘘无显著差异。
在这项研究中，ORT、转化率和估计出血量随着世代的变化而降低，而患者的不良预后并没有增加。这些发现表明，基于熟练程度的课程加上指导可以安全地将经验较少的外科医生引入 RPD，而不会影响患者的安全。
