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Commentary and Perspective

It May Be More Than Age and Experience

Commentary on an article by Patrick J. Cahill, MD, et al.: “The Effect of Surgeon Experience on Outcomes of Surgery for Adolescent Idiopathic Scoliosis”

Bridwell, Keith H. MD1,*

Author Information
The Journal of Bone and Joint Surgery: August 20, 2014 - Volume 96 - Issue 16 - p e144
doi: 10.2106/JBJS.N.00560
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Commentary

This is a very interesting study of the outcomes of adolescent idiopathic scoliosis surgery that compared young surgeons with veteran surgeons. The authors chose five years of experience as the threshold. Many surgeons voice that it takes about five years to become a mature surgeon, so I presume this is why the authors chose this threshold, which seems reasonable. Candidate membership in the Scoliosis Research Society (SRS) lasts five years1.

Regarding the number of cases, the two surgeon groups were unbalanced, with many more cases being performed by the veteran surgeons than by the young surgeons. This could be a problem if most of the surgical procedures in the smaller group were performed by one surgeon2.

The authors did a very good job of following the patients and studying the appropriate radiographic and clinical parameters. They found several statistical differences between the two groups. The operative values that differed most significantly were duration of surgery and mean estimated blood loss. Among postoperative SRS results, scores for function differed the most. It is of interest that there was no significant difference between the two groups in terms of satisfaction. The radiographic correction was the same in both groups.

The results raise a number of questions. Why was the estimated blood loss higher and duration of surgery longer for the younger surgeons? The assumption and premise of this paper is that it was due to a lack of experience, but it could be a result of other factors. For example, it could be that the young surgeons perform more posterior column osteotomies because they believe they need to bill more RVUs (relative value units) to make up for not performing as many surgical procedures as the veteran surgeons perform. It could be that the younger surgeons do not always get 7:30 a.m. start times with experienced scrub nurses, anesthesia teams, and assistants. It would seem likely that the experienced surgeons start at 7:30 a.m. and have an anesthesia team that is experienced in doing spinal-deformity procedures and using antifibrinolytics. The veteran scrub nurses may want to scrub in with the veteran surgeons and not with the young surgeons whom they do not know as well. It could be that the fellow or senior resident scrubs in with the senior attending, and the younger attending may be performing the surgery with an intern.

If the radiographic outcomes did not differ significantly between the young and veteran surgeons, why should the clinical outcomes be different? The patients of the young surgeons had longer surgical procedures and lost more blood, but they did not have a higher rate of complications. So why was the improvement in SRS outcomes lower for the young surgeons than for the veteran surgeons? It is possible that the less experienced surgeons do not have established nurse practitioners and office nurses to counsel patients preoperatively and postoperatively, informing patients on what to expect and helping patients along in the hospital and during the first few months postoperatively. Many of the differences between the young and veteran surgeons may be the lack of a team available for the young surgeon.

Psychosocial and economic factors might also be important. It could be that the health insurance and economic base of the young surgeons’ patient population is not the same as that of the veteran surgeons’ patients. The overall stress of going through surgery, paying for it, and recovering from it might be greater for the patients of the young surgeons and their families than for those treated by the veteran surgeons.

What should the impact of the data in this study be on the management of patients with idiopathic scoliosis? Will insurance companies view these data and decide they will not pay for a higher amount of blood loss or longer surgical procedures and only authorize surgery for patients who are being treated by surgeons with five or more years of experience? Will this change how veteran surgeons help younger surgeons at their respective institutions? I know when I finished my spine fellowship, it was close to three years into my practice before I operated on my first insured patient with idiopathic scoliosis. For the spinal deformity surgeon, a teenage patient with idiopathic scoliosis is the most sought-after case. These patients have the best insurance, the cases are not exceedingly long and stressful, and the results are usually quite good, as demonstrated by the present study, even if there is high blood loss and a long surgery. Veteran surgeons are not likely to want to give up these cases to their younger partners. They work hard to get these referrals and may believe they have earned a rite of passage.

It is surprising, regarding the young surgeons in the study, that the duration of surgery was almost twice as long and blood loss more than twice as great as that of the veteran surgeons. An average blood loss of 2 L is alarming and would be expected for a patient with Duchenne muscular dystrophy undergoing surgery from T3 to the sacrum and pelvis without utilization of an antifibrinolytic or for an adult patient with spinal deformity having multiple osteotomies. An average duration of almost eight hours is alarmingly high as well. Nonetheless, length of hospitalization was about the same for both groups, complications were the same, and both groups did well in terms of radiographic and SRS outcome parameters. This tells us the idiopathic scoliosis population is a healthy, resilient population that will do well with surgical treatment, even if circumstances are not ideal.

I have tried to raise questions rather than give answers. Thank you for giving me the opportunity to share this perspective.

*The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

References

1. Scoliosis Research Society. Membership. www.srs.org/professionals/membership/index.htm. Accessed 2014 May 16.
2. De Winter JCF. Using the Student’s t-test with extremely small sample sizes. Pract Assess Res Eval. 2013;18(10):1-10.
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