Variation and Acquisition of Complex Techniques

Abstract

Background Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between techniques. We used pancreaticoduodenectomy as a model to catalogue variability between surgeons and investigate factors that affect fellows' acquisition of techniques. Materials and methods Semistructured interviews and operative note analysis were conducted to determine techniques of 5 attending surgeons, and these data were mapped to identify variations. Identical interviews and questioning were completed with 4 fellowship graduates whose practice includes pancreaticoduodenectomy. Results All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were 21 surgical step data points that differed. Of 5 surgeons, 4 were unable to identify colleagues' techniques. Fellows reported adopting techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Residency training did not strongly influence their choice of technique; however, senior partners after fellowship did influence technique. Conclusions The number of variants of pancreaticoduodenectomy based on granular, step-by-step differences is larger than previously described. Results hint that variation may be furthered by the fact that surgeons are not aware of the techniques used by colleagues. Fellows choose techniques based on factors not directly related to their own outcomes but rather mentor factors. Whether fellows adopt techniques that will be optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.

How Do Thresholds of Principle and Preference Influence Surgeon Assessments of Learner Performance?

“…Asch et al 39 showed that imprinting of procedural variations and their associated complication rates may follow surgeons from their postgraduate training programs to their jobs in independent practice. And, most convincingly, Davidson et al 40 used the example of pancreaticoduodenectomy to demonstrate that although surgical procedures may in theory have relatively few variations, in practice they are significantly more complex. Davidson et al 40 closely examined the pancreaticoduodenectomy of 5 surgeons and found they differed in "steps and techniques employed" (p. 2) for 7 major areas of the procedure and 21 minor areas.…”

“…And, most convincingly, Davidson et al 40 used the example of pancreaticoduodenectomy to demonstrate that although surgical procedures may in theory have relatively few variations, in practice they are significantly more complex. Davidson et al 40 closely examined the pancreaticoduodenectomy of 5 surgeons and found they differed in "steps and techniques employed" (p. 2) for 7 major areas of the procedure and 21 minor areas. They concluded that each of the 5 surgeons in the study essentially performed 5 different procedures but "all called (it) a Whipple's procedure" (p. 2) .…”

“…They concluded that each of the 5 surgeons in the study essentially performed 5 different procedures but "all called (it) a Whipple's procedure" (p. 2) . 40 Although surgical procedures may be commonly thought to be as uniform as the textbook, close examination reveals meaningful heterogeneity in practice.…”