5 spine surgeons weigh in on professional development & the inevitable learning curve


Here five spine surgeons weigh in on best practices when incorporating a new technique into your practice.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.


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Question: What advice do you have for physicians dealing with the learning curve when learning new techniques?


J. Brian Gill, MD, MBA, Nebraska Spine Hospital, Omaha: The most important advice is be patient. It is easy to get frustrated and revert back to the "old and comfortable" way of doing something. Also, give it time as you will not perfect the technique after two attempts or even five attempts, but you will get to the point where it becomes easier. Every year I strive to learn a new technique. Over a career that's a lot of "new" techniques and development, professionally. I think it is fun to learn something new and then look back a few years to what you used to do and see how much better you are now as compared to then.

Brian R. Gantwerker, MD, The Craniospinal Center of Los Angeles: Most new techniques should be attempted in the simplest of cases. In my career, usually that is not possible. A patient presents with a more complicated case and the new technique becomes essential to treat the patient. In that kind of situation, the curve is potentially vertical. Reaching out to colleagues, if possible, or collecting as much information on technique and one-on-one interaction with an experienced representative is critical. That being said, don't be a hammer looking for a nail. The natural inclination of many clinicians is to learn a new technique and then use it on cases where something simpler is preferable and ideal.   


Vladimir Sinkov, MD, New Hampshire Orthopaedic Center, Nashua: Continued learning, including learning new procedures, is a necessary part of any surgeon's career. Just because something is new, however, it does not necessarily mean it is better. I have gone through this learning curve several times in the past several years, mostly learning new MIS techniques. Just like with any other new treatment, the surgeon should first do his/her due diligence and decide if the new technique offers benefits to the patient beyond those offered by the established procedure. Then, the surgeon should learn the technique from current experts on the subject matter. This includes attending conferences, going to cadaver labs and observing live surgeries. If possible, observing a surgeon and then repeating the procedure the same day on a cadaver offers the best learning in my opinion.  


Once the surgeon is proficient with the technique on the cadaver and has learned the "tips and tricks" from the expert, he or she can apply it in clinical practice. I would start with simple, straightforward cases on healthy patients and expect the first 10 to 15 cases to be the learning curve. I would schedule double the time it usually takes to do such procedure in the beginning. It is critical to also have the "plan B" during those cases and be able to switch back to a well-known technique if things are not working out as planned, for example, having the open lumbar fusion instruments and implants available during first several MIS TLIF cases.


Plas T. James, MD, Atlanta Spine Institute: I think the first piece of advice is based on the old-fashioned "see one, do one, teach one" philosophy. First of all, you need to see procedures and techniques many times and actually go to a hands-on course, not a webinar, where they have a cadaver. There is no substitute for hands-on training and live observation. Second, I think it's important to be able to watch a couple of surgeries with surgeons who do the procedure or have done it in the past. Either observe on the sidelines, or if possible, scrub in on the case. Then, try to line up more than one case at a time, so you can do several surgeries back-to-back as opposed to doing one here and there. You want to line it up so you can do two or three in a row and get proficient with new technology. Basically, you want to get to a point where you can teach it yourself, and teach it to somebody else. But you've got to do it more than once — you've got to do some volume more than anything. It's always good to have hands-on experience.


Srdjdan Mirkovic, MD, NorthShore Orthopaedic Institute, Evanston, Ill.: Physicians first need to evaluate the risks and benefits regarding the potential complications that could come with learning a new technique. In doing so, study the basic science behind the new technique. One's decisions should be based on science rather than competition and their marketing that the latest is the greatest. Sometimes it's not.


Also, note if the new technique prioritizes the length of surgery. We always strive for a quicker surgery, but not to the detriment of basic science and a better surgical outcome. Be cautious when hearing pronouncements by so-called "experts" at industry-generated meetings who claim no complications in a case study in which they present. Some claims defy scientific knowledge and common sense.


Look closely at patient outcomes and if the diagnosis and patient fit the new treatment. Despite the popularity of minimally invasive and laser surgeries in spine care, a certain diagnosis for a certain patient might mean more invasive surgery is most appropriate.


Then ask yourself: Would I perform this new technique on a close family member or friend. If you think it's good enough for them, then it will be effective for patients.


Finally, above all, know yourself. What is your comfort level in taking on a new technique? There's always an investment in time and resources, so take on only what you think you can handle.


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