Intended for healthcare professionals

Education And Debate

New surgical procedures: can we minimise the learning curve?

BMJ 2000; 320 doi: (Published 15 January 2000) Cite this as: BMJ 2000;320:171
  1. A Hasan (, consultant paediatric cardiac surgeona,
  2. M Pozzi, consultant paediatric cardiac surgeonb,
  3. J R L Hamilton, consultant paediatric cardiac surgeona
  1. a Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne NE7 7DN
  2. b Department of Surgery, Royal Liverpool Children's Hospital, Liverpool L12 2AP
  1. Correspondence to: A Hasan
  • Accepted 13 July 1999

The Ross procedure for aortic valve replacement was introduced at two paediatric cardiac centres (Freeman Hospital, Newcastle, and Royal Liverpool Children's Hospital) where surgeons had no previous experience of this technique. A structured programme of training and cooperation between the two centres enabled surgeons to minimise the learning curve for this procedure. We share our experience and suggest options for surgeons who wish to undertake new procedures in the current era of surgical practice and clinical governance. Issues of informed consent and risk stratification remain.

Summary points

Surgeons have always recognised the concept of a learning curve when undertaking a new procedure

Recent events mean that there is a lack of professional and public tolerance for suboptimal results due to a learning curve

Learning a new technique, even for an established consultant, requires some sort of learning curve

Introducing a new procedure in a structured way that incorporates formal training courses, cadaveric resection, and assistance from expert practitioners can reduce the learning curve


The recent General Medical Council (GMC) inquiry into the Bristol Paediatric Cardiac Surgical Unit highlighted many concerns common to all surgical specialties. At the end of the judgment, the president of the GMC listed 13 issues that the professions should address, and the senate of surgery recently published its response.1 The concept of a learning curve, which has long been recognised by surgeons, was of particular consequence. However, the senate responded that “there should be no learning curve as far as patient safety is concerned.”1 To learn to perform a new procedure without having a learning curve is a dilemma that we, as established consultants in paediatric cardiac surgery, faced when we wanted to introduce the Ross procedure into our surgical practice.

We discussed strategies which we hoped would reduce the steepness of our learning curve, and …

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