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Fellowship Training as a Modifier of the Surgical Learning Curve

Purpose To investigate the effects of fellowship training on a surgeon's learning curve for cancer control after open radical prostatectomy. Method The study cohort included 7,765 prostate cancer patients who underwent radical prostatectomy performed by 1 of 72 surgeons at four major U.S. academic medical centers between 1987 and 2003. Multivariable models were used to determine the learning curves for biochemical recurrence and surgical margins, separately for surgeons with and without fellowship training, after adjustment for standard prognostic variables. Results Initial results for fellowship- and non-fellowship-trained surgeons were similar (five-year probability of recurrence for first case: 19.4% and 18.3%, respectively; absolute difference: −1.1%; 95% confidence interval [CI]: −5.5%, 3.0%; P = .7). However, the rate of learning was faster among fellowship-trained surgeons (P = .006), which resulted in their overall superior cancer control (P = .001; difference: 4.7%; 95% CI: 2.6%, 7.4%). With regard to positive surgical margin rates, fellowship-trained surgeons initially had superior results than did non-fellowship-trained surgeons (P = .005; 36% versus 42%; absolute difference: 6%; 95% CI: 1%, 10%), but the difference between the groups' subsequent learning curves was not significant (P = .9 for interaction). Conclusions The learning curve for biochemical recurrence depends on surgical training, whereas the learning curve for surgical margins does not. This difference suggests that improvements in margin rates result from reflection on specific aspects of surgical procedure, whereas improvements in biochemical recurrence occur by some general process of improvement in surgical technique. Further research into the mechanisms of surgical learning is warranted.