Commentary: The sky's the limit, but where's the ground?

Abstract

Surgical outcomes of acute type A aortic dissection (aTAAD) repair have improved over the past several decades, 1 but it remains an operation with significant morbidity and mortality due to preoperative physiologic compromise and the complexity of operative repair. Factors such as shock or malperfusion syndrome may lead to extremely poor outcomes. 2 Optimizing surgical outcomes requires expedient, prudent decisions about operative conduct, including cannulation, cerebral perfusion, hypothermia, and extent of repair, as well as efficiency of such conduct. Accordingly, there may be concern about how early-career surgeons may gain these skills without compromising patient care. Objective data are important, given that subjective perceptions of a surgeon's readiness for operative independence differ between senior and junior surgeons. 3 Lin and colleagues 4 examine the learning curve of aTAAD operations performed by early-career cardiovascular surgeons. The study raises a number of questions around training philosophy in cardiac surgery. First, what is an early-career surgeon? Traditional views define this according to the number of years posttraining. By contrast, the current paradigm of medical education is based on competency rather than time. Lin and colleagues 4 apply this concept by use of cumulative sum failure analysis, defining a threshold number of aTAAD operations derived from average institutional outcomes. Outcomes were excellent, with 30-day mortality of 11.7%. Their principal finding was that mortality and morbidity outcomes were similar between earlycareer and senior surgeons, both overall and in the subgroup of patients with predictors of poor outcomes.