Complications Read Online Free PDF Page B

babies died blue, fatigued, never knowing what it was to get enough breath. For years, switching the vessels to their proper positions wasn’t technically feasible. Instead, surgeons did something known as the Senning procedure: they created a passage inside the heart to let blood from the lungs cross backward to the right heart. The Senning procedure allowed children to live into adulthood. The weaker right heart, however, cannot sustain the body’s entire blood flow as long as the left. Eventually, these patients’ hearts failed,and although most made it to adulthood, few lived to old age. Then, by the 1980s, a series of technological advancements made it possible to do a switch operation safely. It rapidly became the favored procedure. In 1986, the Great Ormond Street surgeons made the changeover, and their report shows that it was unquestionably a change for the better. The annual death rate after a successful switch procedure was less than a quarter that after the Senning, resulting in a life expectancy of sixty-three years instead of forty-seven. But the price of learning to do it was appalling. In their first seventy switch operations, the doctors had a 25 percent surgical death rate, compared with just 6 percent with the Senning procedure. (Eighteen babies died, more than twice the number of the entire Senning era.) Only with time did they master it: in their next hundred switch operations, just five babies died.
    As patients, we want both expertise and progress. What nobody wants to face is that these are contradictory desires. In the words of one British public report, “There should be no learning curve as far as patient safety is concerned.” But that is entirely wishful thinking.
    Recently, a group of Harvard Business School researchers who have made a specialty of studying learning curves in industry—in making semiconductors, building airplanes, and such—decided to examine learning curves among surgeons. They followed eighteen cardiac surgeons and their teams as they took on the new technique of minimally invasive cardiac surgery. This study, I was surprised to discover, is the first of its kind. Learning is ubiquitous in medicine, and yet no one had ever compared how well different clinicians actually do it.
    The new heart operation—involving a small incision between ribs instead of a chest split open down the middle—proved substantially more difficult than the conventional one. Because the incision is too small to admit the usual tubes and clamps for rerouting blood to the heart-bypass machine, surgeons had to learn a trickier method, which involved balloons and catheters placed through groin vessels.They had to learn how to operate in a much reduced space. And the nurses, anesthesiologists, and perfusionists all had new roles to master, too. Everyone had new tasks, new instruments, new ways that things could go wrong, and new ways to fix them. As you’d expect, everyone was found to experience a substantial learning curve. Whereas a fully proficient team takes three to six hours for such operations, these teams took an average of three times longer for their early cases. The researchers could not track rates of morbidity in detail, but it would be foolish to imagine that these rates were not affected.
    What’s more interesting is that researchers found striking disparities in the speed with which different teams learned. All teams received the same three-day training session and came from highly respected institutions with experience in adopting innovations. Yet, in the course of fifty cases, some teams managed to halve their operating time while others failed to improve at all. Practice, it turned out, did not necessarily make perfect. Whether it did, the researchers found, depended on
how
the surgeons and their teams practiced.
    Richard Bohmer, the one physician among the Harvard researchers, made several visits to observe one of the quickest-learning teams and one of the slowest, and he was