correspondence
Surgical Skill and Complication Rates after Bariatric Surgery To the Editor: Birkmeyer et al. (Oct. 10 issue)1 report that peer ratings of the technical skill of bariatric surgeons correlated with patient outcomes as measured according to complication rates — the higher the peer rating of technical skill, the lower the rate of complications. This finding may be true for laparoscopic bypass surgery performed by bariatric surgeons, but it may not hold true for other types of surgery. The study involved an operative procedure in which the technique is fairly standard. To suggest that the same findings may be observed in other procedures in which surgical approaches, techniques, and instruments vary significantly2,3 would be preliminary. Furthermore, although the authors use the term “surgeon,” there are considerable differences in the technical aspects of various surgical subspecialties.2 In rapidly advancing fields such as neurosurgery in which operative techniques are constantly changing,2,3 it is unclear whether peer ratings of technical skill are feasible, since variations in surgical technique are so diverse. Brian J. Dlouhy, M.D. Prince of Wales Hospital Sydney, NSW, Australia [email protected]
Rajesh C. Rao, M.D. University of Michigan Medical School Ann Arbor, MI No potential conflict of interest relevant to this letter was reported. 1. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and
complication rates after bariatric surgery. N Engl J Med 2013; 369:1434-42. 2. Lin Z, Zecca M, Sessa S, et al. Objective skill analysis and assessment in neurosurgery by using an ultra-miniaturized inertial measurement unit WB-3 — pilot tests. Conf Proc IEEE Eng Med Biol Soc 2009;2009:2320-3. 3. Choudhury N, Gélinas-Phaneuf N, Delorme S, Del Maestro R. Fundamentals of neurosurgery: virtual reality tasks for training and evaluation of technical skills. World Neurosurg 2013;80(5): e9-e19. DOI: 10.1056/NEJMc1313890
To the Editor: Birkmeyer et al. report a very interesting association between independently rated surgical skill and patient outcomes. They highlight the risk of rater bias and have taken
steps to minimize its impact; however, it seems salient to question whether there also existed a participant bias, with only surgeons who were more confident in their operative skills volunteering to be filmed. The operative-skill scores assigned to the participants all fell within an acceptable and relatively narrow standard of practice. It would be interesting to know the extent of the association between outlier performance and surgical outcomes with the use of this experimental method. If this valuable study is to contribute to the evidence base for new systems of clinical governance, as it undoubtedly should, it should be considered in the context of this limitation. Piers Page, M.R.C.S. (Ed.) Brighton and Sussex University Hospitals National Health Service Trust Brighton, United Kingdom [email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1313890
To the Editor: In the study by Birkmeyer et al., a selection bias was induced by allowing surgeons to choose which recorded procedure they sent for evaluation. The chosen procedure may not reflect the average technical-skill level of a surgeon (less skilled surgeons may have a “day of inspiration”). This bias is probably self-corrected by the fact that most surgeons will send their best performances, and the best tapes of less skilled surgeons will not show the level of expertise that is shown in the best tapes of more skilled surgeons. Online live evaluation of procedures performed in patients with comparable features would have given a higher internal validity to the study. David Julià, M.D. Núria Gómez, M.D. Antoni Codina-Cazador, M.D., Ph.D. Hospital Universitari Doctor Josep Trueta Girona, Spain [email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1313890
n engl j med 370;3 nejm.org january 16, 2014
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The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF NEW SOUTH WALES on August 10, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
Surgical Skill and Complication Rates after Bariatric Surgery To the Editor: Birkmeyer et al. (Oct. 10 issue)1 report that peer ratings of the technical skill of bariatric surgeons correlated with patient outcomes as measured according to complication rates — the higher the peer rating of technical skill, the lower the rate of complications. This finding may be true for laparoscopic bypass surgery performed by bariatric surgeons, but it may not hold true for other types of surgery. The study involved an operative procedure in which the technique is fairly standard. To suggest that the same findings may be observed in other procedures in which surgical approaches, techniques, and instruments vary significantly2,3 would be preliminary. Furthermore, although the authors use the term “surgeon,” there are considerable differences in the technical aspects of various surgical subspecialties.2 In rapidly advancing fields such as neurosurgery in which operative techniques are constantly changing,2,3 it is unclear whether peer ratings of technical skill are feasible, since variations in surgical technique are so diverse. Brian J. Dlouhy, M.D. Prince of Wales Hospital Sydney, NSW, Australia [email protected]
Rajesh C. Rao, M.D. University of Michigan Medical School Ann Arbor, MI No potential conflict of interest relevant to this letter was reported. 1. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and
complication rates after bariatric surgery. N Engl J Med 2013; 369:1434-42. 2. Lin Z, Zecca M, Sessa S, et al. Objective skill analysis and assessment in neurosurgery by using an ultra-miniaturized inertial measurement unit WB-3 — pilot tests. Conf Proc IEEE Eng Med Biol Soc 2009;2009:2320-3. 3. Choudhury N, Gélinas-Phaneuf N, Delorme S, Del Maestro R. Fundamentals of neurosurgery: virtual reality tasks for training and evaluation of technical skills. World Neurosurg 2013;80(5): e9-e19. DOI: 10.1056/NEJMc1313890
To the Editor: Birkmeyer et al. report a very interesting association between independently rated surgical skill and patient outcomes. They highlight the risk of rater bias and have taken
steps to minimize its impact; however, it seems salient to question whether there also existed a participant bias, with only surgeons who were more confident in their operative skills volunteering to be filmed. The operative-skill scores assigned to the participants all fell within an acceptable and relatively narrow standard of practice. It would be interesting to know the extent of the association between outlier performance and surgical outcomes with the use of this experimental method. If this valuable study is to contribute to the evidence base for new systems of clinical governance, as it undoubtedly should, it should be considered in the context of this limitation. Piers Page, M.R.C.S. (Ed.) Brighton and Sussex University Hospitals National Health Service Trust Brighton, United Kingdom [email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1313890
To the Editor: In the study by Birkmeyer et al., a selection bias was induced by allowing surgeons to choose which recorded procedure they sent for evaluation. The chosen procedure may not reflect the average technical-skill level of a surgeon (less skilled surgeons may have a “day of inspiration”). This bias is probably self-corrected by the fact that most surgeons will send their best performances, and the best tapes of less skilled surgeons will not show the level of expertise that is shown in the best tapes of more skilled surgeons. Online live evaluation of procedures performed in patients with comparable features would have given a higher internal validity to the study. David Julià, M.D. Núria Gómez, M.D. Antoni Codina-Cazador, M.D., Ph.D. Hospital Universitari Doctor Josep Trueta Girona, Spain [email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1313890
n engl j med 370;3 nejm.org january 16, 2014
285
The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF NEW SOUTH WALES on August 10, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
