Annex A > Chapter 14 - Care in the Operating Theatre and the `Learning Curve' > The `learning curve' > Defining the `learning curve'
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Defining the `learning curve'
80 Mr Julian Dussek, President of the Society of Cardiothoracic Surgeons, in his paper for the Society entitled `Avoiding the Learning Curve', wrote:
`The inference to be drawn from the phrase "learning curve" in the context of cardio-thoracic surgery is that there is an expected and acceptable excess of patients who will die or be harmed in the early experience of a learner but who would have fared better if they were operated upon by a surgeon who is on the plateau of experience.' [95]
`A "Learning Curve" is learning from experience about a new procedure, particularly in the initial phase, but also continuing beyond that.' [96]
`It is probably not inevitable, and in principle it is possible that a learning curve might not happen, but I believe that it will usually be present and measurable. My own experience indicates that the learning curve is a real phenomenon. Regardless of whether it is inevitable or not, the imperative is always to minimise the learning curve.' [97]
83 Mr Dhasmana stated in his written evidence to the Inquiry:
`The learning curve in a clinical setting is very difficult to define and defend. In any technical field there are bound to be "failures", which improve with increased experience. In complex and technically demanding operations like Arterial Switch, failure usually means loss of life, which is totally unacceptable to any surgeon. Unfortunately it occurs. Though it is unacceptable, its inevitability is well recognised ... there is no clear-cut definition of an acceptable length of time period for the completion of this learning curve, although there is some indication that the period could be less in "High Volume" centres.' [98]
`I believe that it is inevitable that anyone undertaking a new procedure will experience a "learning curve" during which results may fall below those of someone more experienced in the technique.
`It seems inevitable that learning curves must exist if new forms of treatment are ever to get started and advance medicine for patients. It is the minimising of the learning curve which is important in maintaining acceptable levels of performance.' [99]
`I accept that for every new procedure there is a learning curve during which the results may fall below standard. I think it is, however, important that any new surgical procedure is carried out with the support and with full discussion with all the rest of the surgical team members, and the complications which are bound to occur are equally openly discussed.' [100]
86 Mr Jaroslav Stark, consultant paediatric cardiothoracic surgeon and a member of the Inquiry's Expert Group, described `the learning curve' as an experimental period in the development of a procedure:
`... all the new operations you may in summary call "experiments" because you can not experiment on animals because you do not have the animal model, and even if you had the animal model we are not ... allowed to try the operations on animals ... So to some extent "experimenting" sounds a harsh word, but I think it was.' [101]
87 Professor Sir Kenneth Calman, Chief Medical Officer for England 1991 to 1998, commented:
`If it is an entirely new procedure you are going to pioneer yourself, you are likely to have done some of that in some kind of experimental way beforehand to ensure the outcome is likely to be what you think it will be ...' [102]
88 Dr Robin Martin, consultant cardiologist, told the Inquiry:
`... any time you make a treatment strategy there is a risk of a learning curve, a change in outcome for that group ... What you are dealing with here still is a relatively small group of patients compared with [the] rest of our throughput ... You see fluctuations in different groups at any one time. That makes it I think always difficult for us to analyse exactly what is happening with individual [small] groups of patients.' [103]
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Footnotes
[95] SCS 0003 0002; paper dated 13 September 1998
[96] WIT 0120 0336 Mr Wisheart
[97] WIT 0120 0336 Mr Wisheart
[98] WIT 0084 0115 Mr Dhasmana
[99] WIT 0318 0009 Dr Underwood
[100] WIT 0073 0008 Professor Angelini