Intended for healthcare professionals


Surgeons take as long as 15 years to reach peak performance, study shows

BMJ 2015; 350 doi: (Published 01 June 2015) Cite this as: BMJ 2015;350:h2950
  1. Anne Gulland
  1. 1BMJ Careers

Surgeons hit a plateau in their performance of 1-15 years depending on the procedure they are performing, a study in the Annals of Surgery has shown.1

A systematic review of 57 studies looking at the influence that experience and the number of procedures carried out have on individual surgeons’ performance found that, after an initial learning phase, surgeons hit a plateau in performance.

This level is reached at any time from one to 15 years, or 25 to 750 cases, depending on the complexity of the procedure, the authors found. For example, single port laparoscopic cholecystectomy can be learned in eight cases, whereas it takes at least five years to learn septomeatoplasty, the authors found.

They wrote that the presence of the plateau phase was important, as it suggested that training exercises and simulations would benefit surgeons only in the early phases of learning a procedure. They added that the study had implications for the design of the surgical curriculum, saying that it should take into account years of experience and the number of cases performed. “It may be preferable to evaluate trainees on the basis of their patient risk adjusted outcomes, permitting graduation once a plateau phase has been reached, rather than basing competency on number of cases or years of experience alone,” the authors said.

Some 44 studies showed that, in the initial learning phase, health outcomes increased across measures with the more cases a surgeon performed. These measures included operative time, operative time variability, recurrence rate, conversion rate, intra- and peri-operative complications, blood transfusions, stroke, mortality, and blood loss.

Some studies showed that surgeons’ performance worsened after the plateau phase. One study looking at thyroidectomy showed that, after 20 years of practice, outcomes started to decline. Another found that, among surgeons aged over 45, the risk of recurrence in a patient after laparoscopic inguinal hernia repair increased by 1.72 times when compared with less experienced surgeons.

Majd El-Harasis, one of the study authors and a researcher at Imperial College London, said that it would be controversial to lower the age limit for surgeons operating on patients. He said, “It’s important for surgeons to be aware of their performance metrics and observe trends over time, to address areas of potential improvement before a deterioration occurs.”

The authors could not pinpoint the reason for the deterioration but said that mental fatigue, poorer compliance with evidence based medicine, or reduced stress tolerance may be to blame. Another factor could be that senior surgeons are more likely to be involved in administration, teaching, or research and therefore perform fewer procedures.

El-Harasis said that more studies looking at individual procedures were needed but that it was important for hospitals to be aware of the potential for declining performance. “We need to ensure that hospitals and surgical departments have mechanisms in place to monitor individual surgical performance and identify areas for potential intervention before any deterioration takes place. We also need more studies comparing learning curves between procedures and specialties,” he said.

Derek Alderson, a Royal College of Surgeons council member, said that the decline in performance may be attributed to the fact that senior surgeons take on the most high risk patients. “This study was unable to take this into account,” he said.

Alderson added, “Better results with time may well simply reflect other aspects of patient care that have led to better outcomes rather than a real change in the surgeon’s abilities.

“Hospital factors, such as better tests to detect disease earlier, improved selection of patients for surgery, intensive care and enhanced recovery facilities, along with better recognition and treatment of complications, all lead to better outcomes.”