The Fallacy of the “Learning Curve”

The orthopaedic literature is replete with articles discussing the attainment of surgical expertise, the so-called learning curve. Such papers are usually prompted by new orthopaedic implants, novel techniques, or adoption of new technology. Recent learning curve submissions have increased with the expansion of total ankle arthroplasty, 3D-printed implants, and minimally invasive surgeries. Whether or not the introduction of each new surgical implant or technique warrants a unique learning curve study remains unknown.

Learning curve manuscripts often focus on surgical time as the main measure of proficiency. However, surgical time does not necessarily equate to surgical competence or to quality outcomes. Surgical time is a multifaceted measure of a complex interworking of surgeons, nurses, anesthesia providers, assistants, and radiology technicians, as well as the timely availability of surgical equipment and implants. Other benchmarks commonly used in learning curve studies, such as predefined checklists of skills needed for proficiency, can appear arbitrary. Operative simulations may help surgeons practice new techniques, but do not directly translate to the in vivo clinical setting treating actual patients.

Learning curve data are also not generalizable to all surgeons or surgical settings. Many learning curve studies arise within university or academic settings, possibly creating selection bias. Consequently, implant designers would have a greater familiarity with the new procedure or devices, which would not necessarily translate to other surgeons at large. Adopters of new techiniques and devices clearly progress at different speeds, so published data by one group may not apply universally to others.

Setting case volume thresholds for surgical proficiency or technical expertise, as many learning curve manuscripts do, is particularly problematic in the current regulatory and legal climate. If the orthopaedic literature is seen to endorse case volume as a proxy for competence, it is not hard to imagine hospitals, ambulatory surgery centers, and even credentialing or licensing boards requiring documented case volumes before allowing surgeons to perform more newly introduced procedures. This could lead to a “Catch-22” whereby surgeons cannot perform the procedures to attain the necessary experience. Finally, reliance on case volume data could be counterproductive in the legal environment, where surgeons could potentially find themselves at risk if not meeting such thresholds as they provide contemporary orthopaedic care.

The Editorial Board of Foot & Ankle International and Foot & Ankle Orthopaedics has therefore concluded that manuscripts on learning curve studies do not reliably serve our readership or our field. The journey of surgical learning is endless. Mastery in surgery is an asymptotic goal, rather than an achievable endpoint. We believe that surgeons rightly strive for continual improvement and expertise rather than for “good enough” thresholds defined by overly simplified or flawed methods. For these reasons, learning curve manuscripts will no longer be considered for publication, with the hope that all surgeons will strive for lifelong learning and continuous refinement of their surgical proficiency in the relentless pursuit of excellence.

John T. Campbell, MD George B. Holmes Jr, MD Christopher P. Chiodo, MD Thomas O. Clanton, MD Ellie Pinsker, PhD Stefan Rammelt, MD, PhD Robert A. Vander Griend, MD Charles L. Saltzman, MD