Annex A > Chapter 14 - Care in the Operating Theatre and the `Learning Curve' > The `learning curve' > Managing the `learning curve'

Managing the `learning curve' [104]

89 Dr Underwood stated in her written evidence to the Inquiry:

`I believe it may be possible to shorten a learning curve by good theoretical knowledge of the new procedure, observing others with experience, training alongside others and then working with decreasing supervision by the experienced operator, in the same way that a trainee learns new skills.' [105]

90 Mr Wisheart, in his written evidence to the Inquiry, suggested that the following steps could be taken:

• `Private preparation which includes reading, attending meetings, courses etc.
• `Visiting centres of "excellence" and observing there.
• `Visiting centres of "excellence" and having an opportunity to assist the experienced surgeon at an operation.
• `Attending workshops dedicated to promoting technical proficiency in specific procedures.
• `Inviting experts to operate or assist the surgeon in his own centre.' [106]

91 He went on:

`... it will always be a different experience when a surgeon does an operation for himself for the first time.' [107]

92 Professor Angelini explained, in his written evidence to the Inquiry, how he approached a new procedure:

`Any time I have embarked on a new surgical procedure, and this has happened on several occasions since 1992, I usually have gone to visit centres where those procedures were carried out, and subsequently have invited the expert(s) to Bristol to help me with the surgery. This has often been with regard to both surgical and anaesthetic expertise.' [108]

93 Professor Sir Kenneth Calman told the Inquiry of his experience:

`I was involved surgically, for about eight years, mainly on transplantation and vascular surgery. During that process, the senior consultant I worked with took a year out to go and work in the United States on liver transplantation. He would not have done a liver transplant on his own in this country without a year's experience with one of the most outstanding liver transplant surgeons in the world. That would be the way he would deal with an entirely new procedure: he would normally go somewhere where they are doing it and learn how it is done, come back with the skills and expertise and build up a team.' [109]

94 Sir Barry Jackson discussed the extent to which there were formal requirements to be followed, in the following exchange:

`Q. ... what would be the expectations as to the practical steps that had to be taken before a person could be confident or reasonably confident that actually they would not be harming their patient if they embarked on something relatively new?

`A. There was nothing laid down about this. It was not formalised. It was up to an individual surgeon to take what steps they considered necessary to enable them to carry out that operation with a clear conscience.

`Q. So perhaps there might be a range of steps available to them. The obvious one would be to review the literature to make sure they were familiar at least in theory with the steps that needed to be taken in performing this new technique. That presumably is something that everybody would have been aiming to do during the period with which we are concerned?

`A. Yes, well, without either reading the literature, reading the technique in an article ... or seeing a video, and videos were widely used at this time, or having seen the operation in somebody else's operating theatre when visiting another surgeon, I do not think any surgeon would embark on a new operation without one or other of those steps being taken before they put, as we say in the trade, knife to skin.

`Q. If the first level would be reviewing the literature, the second might be viewing a video; the third step that one might perhaps take would be to visit another centre and watch a colleague perform the procedure.

`How common would that have been as a method of informing oneself across the ...

`A. I think it would have been less common than reading and watching videos, but I cannot quantify it.' [110]

95 In his paper `Avoiding the Learning Curve', Mr Dussek recommended:

`Surgeons should not be performing operations until they are competent to do so at an accepted general level of risk.

`Every surgeon should feel confident that he has the necessary education and experience to perform a new operation skilfully and that this skill should extend where necessary to the peri-operative management.

`Funding must be available for surgeons to attend the necessary training courses ...

`The best way of learning a new procedure is to be taught by an established expert. Therefore facilities must exist whereby visiting consultants can be given honorary contracts with the minimum of fuss. The arrangements for recognised experts from overseas need to be simplified so that they can come at short notice. Possibly the GMC should keep a computerised register of consultants who would be recognised to train in other hospitals.

`Consultants must relinquish a historical reluctance to ask other consultants to help. With the emergence of the new "Calman trainees" [111] with possibly less surgical experience than their predecessors this is going to be of increasing importance.' [112]

<< previous | next >> | back to top

Footnotes

[104] Mr Barry Jackson, President of the Royal College of Surgeons of England, told the Inquiry that the Royal Colleges have since sought to respond to the issue of the `learning curve' through a system called SERNIP, the Safety and Efficacy Register, New Interventional Procedures, introduced in 1996. Mr Jackson explained how SERNIP functioned: `New techniques should be referred to this new body, SERNIP, for a careful assessment as to whether or not this was a technique that could be recommended to Trusts and purchasers for widespread implementation, or whether it needed further refinement, proper controlled trial assessment, or whether it was found wanting.'
See T28 p.104-5

[105] WIT 0318 0009 Dr Underwood

[106] WIT 0120 0341 Mr Wisheart

[107] WIT 0120 0341 Mr Wisheart

[108] WIT 0073 0008 Professor Angelini

[109] T66 p.63-4 Professor Sir Kenneth Calman

[110] T28 p.112-14 Sir Barry Jackson

[111] `Hospital Doctors - Training for the Future, The Report of the Working Group on Specialist Medical Training', DoH 1993

[112] SCS 0003 0005 Mr Dussek