Wednesday, April 10, 2013

Every Transplant Surgeon's Learning Curve

Who should be selected to perform a transplant, a surgeon who has performed 100 prior transplants or one with the experience of 500 previous cases? Most of us would indicate that the more experienced surgeon is the obvious choice. We are intrinsically responding to the desire to have a surgeon who has moved farther along or completed his/her learning curve for that transplant. Noone wants to participate in the early portion of a surgeon's learning curve, do they?

Although that is a logical response, it is also unrealistic. Every surgeon - every single surgeon - has had a personal learning curve. The surgeon should still have active mini-curves for new devices and new procedures that are relevant to his/her practice. No surgeon has been pre-loaded with any of the knowledge, skills or judgement that comprise surgical experience. And, how are new surgeons going to be trained, or experienced surgeons going to learn new procedures (think of when the laparoscopic donor nephrectomy was first introduced) without passing through a respective learning curve. The answer is that they won't.

Patients are protected during learning curves through the collective efforts of transplant teams which mitigate (disperse) most of the risks. This is a specialty that still preserves the old fashioned concept of surgical training as a type of apprenticeship. Trainees are guided and supervised day in and day out by the same mentors who come to know them very, very well. These mentors know their strengths and weaknesses and specifically help to hone their skills both in and out of the operating room. Independent responsibility is permitted on a graded basis and is earned based on performance. The senior mentor is physically present, assisting the learning surgeon but also prepared to assume control if necessary - similar to the 2 pilots in a cockpit. This is the system that protects patients. And, it is a major part of why a transplant team is judged on its collective performance, rather than on the individual providers' outcomes.

Notable too is the challenge of determining when the highly experienced but aging surgeon should stop - or be stopped - from personally performing surgery. This sensitive issue is also mitigated through the team approach, allowing valuable experience to still be put to genuine use.

If it is unreasonable to expect that only the most accomplished and senior (but not too senior) transplant surgeon will be operating, what are reasonable expectations? The identities and backgrounds of those surgeons who participate on the team should be made accessible.  But, presence of a specific transplant surgeon at a transplant center does not translate into accessibility for a specific procedure unless it is a live donor transplant. Deceased donor transplants simply are not scheduled in advance. Consequently, the team's on call structure is very important and determines which surgeon(s) will participate. This reality should be clarified at the time of pre-transplant education. The patient should be able to expect to have a surgeon who has progressed far along a relevant learning curve(s) participate in the impending transplant and should feel empowered to ask directly whether or not this is the case.

Comments from patients and other stakeholders on this post are welcome - please participate in the Comment space below.



  1. DRF the ModeratorMay 1, 2013 at 12:49 PM

    Excellent comments, Doctor!

    I'm a liver recipient (AIH, date 2/18/11; I was a "1a" listing) and I've had a short relationship with transplantation etc. I was initially hospitalized in late January 2011 (Sx: malaise, jaundice - blood test had transaminases in the 1000s and tbili was something like 23; INR was 3.5, etc), stabilized, discharged, and lapsed into hepatic coma (hepatic encephalopathy) and woke up in the ICU 5 days later and was transplanted about a week after that.

    But one thing I thought was absolutely fantastic was the range of experiences by my caregivers: a few "short coat" med students pulled one of my drains out. Interns, 2nd, 3rd years all contributed positively to my care and my experience.

    It's a thrill to be alive and healthy of course, but it's also really cool to be a "data point" that helps future leaders in transplantation along their way.

    The fellow-surgeon who put his initials on me and saw me right before surgery was a model of what you'd want to see. His care was top rate, and because I was a somewhat unusual patient for him, he was really interested in learning more and spent some time chatting. this was both reassuring from a "feeling cared for" perspective; also from a "best level of care" one.

    because there was such a dedication to learning and excellence in my transplant center, I felt that the students, younger docs, heck, the whole team were all at the top of their games, thanks to the intense awareness of learning.

    Medical and surgical physicians share their clinical interests, and they're always eager to discuss what they're learning (even when they're discovering it).

    In my experience, the team of physicians, nurses, NPs, social workers, etc, are all dedicated to keeping patients like me alive and healthy. As no two patients or cases are alike, they have to be constantly willing to learn and confront even the individual patient's learning curve.


  2. Thank you for your insights and support of your transplant team. Congratulations on your transplant.

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