Discussion
Using two statewide datasets from two high-volume states, we showed that
CABG case complexities are evenly distributed across cardiac surgeons of
various experience levels. This is important for several reasons. First,
this shows that in cardiac surgery there is a relatively equal
distribution of high and low risk patients among surgeons of differing
experience levels. This stands in contrast to the findings in other
specialties, such as The Cognitive Changes and Retirement among Senior
Surgeons Study (CCRASS), which found that surgeons self-reported an
increase in case volume and a decrease in case complexity over
time4. The CCRASS was supported by a study which
showed that general surgeons with fewer than 15 years in practice
operated on patients of higher pre-operative risk5.
Another study of vascular surgeons showed that surgeons within their
first 5 years of practice had a greater proportion of nonelective cases
with a higher degree of comorbidities and larger
aneurysms10. To our knowledge, this is the first time
this relationship between surgeon experience and average patient risk
profile has been investigated in cardiac surgery.
Determining whether there is a proportionate distribution of high and
low risk cases for surgeons of all experience levels is valuable, both
for the sake of training and for the sake of patient care. Ensuring
early career surgeons see cases of different preoperative risk and
complexity is likely to be an important feature of comprehensive
competency. On the other hand, some reports have shown that middle to
late career surgeons obtain the best outcomes on complex
operations1,3, which may argue for a distribution of
cases in which the more experienced surgeons receive more of the
high-risk cases to optimize patient outcomes.
Our data also demonstrated that there is no statistically significant
relationship between risk-adjusted outcomes on isolated CABG and surgeon
experience. This is a valuable independent finding for two reasons. It
demonstrates that early-career surgeons demonstrate competency in CABG
surgery, which has been challenged in some
studies11,12 and supported by
others13,14. Secondly, some articles have discussed
whether there should be a maximum age at which surgeons are allowed to
practice15,16. It used to be the case in the United
Kingdom that surgeons could not perform surgery for the Public Health
Service past the age of 65. Our data suggests that this surgeon
age-maximum is not necessary, as late-career surgeons did not
demonstrate inferior outcomes to early-career surgeons on isolated CABG
surgery.