Foot & Ankle International senior editors have announced that the journal will no longer consider learning curve manuscripts for publication.
Foot & Ankle International is the official journal of the American Orthopaedic Foot & Ankle Society. The announcement appeared in a recent editorial entitled “The Fallacy of the ‘Learning Curve.’” The editorial was authored by the following editorial board members: John T. Campbell, M.D.; George B. Holmes Jr., M.D.; Christopher P. Chiodo, M.D.; Thomas O. Clanton, M.D.; Ellie Pinsker, Ph.D.; Stefan Rammelt, M.D., Ph.D.; Robert A. Vander Griend, M.D.; and Charles L. Saltzman, M.D.
The learning curve is also known as a surgeon’s attainment of expertise for specific procedures. The senior editors highlighted a number of reasons for their decision including those discussed below.
First, the senior editors looked at the “focus on surgical time as the main measure of proficiency.” The editors discussed how this focus could be problematic because “surgical time does not necessarily equate to surgical competence or to quality outcomes.” Additionally, surgical time is a complex measure that involves countless variables. Other benchmarks used in learning curve studies were also seen as potentially arbitrary “such as predefined checklists of skills needed for proficiency.”
Next, the senior editors emphasized that learning curve data is not generalizable across all practitioners. This means that data may not equally apply to all groups. For example, if the learning curve studies come from those with more familiarity to the new procedure (such as in an academic setting) it would not necessarily translate to surgeons outside of the realm of familiarity.
Finally, the senior editors found it problematic that many learning curve studies encourage case volume thresholds for surgical proficiency or technical expertise. Notably, where surgeons must have documented case volumes before being allowed to perform new procedures. They emphasized that this could potentially create a “Catch-22” whereby “surgeons cannot perform the procedures to attain the necessary experience.” This could also potentially create legal risks if the thresholds are upheld.
The senior editors concluded by stating that “surgeons rightly strive for continual improvement and expertise rather than for ‘good enough’ thresholds defined by overly simplified or flawed methods.” They emphasized that their decision was made with “the hope that all surgeons will strive for lifelong learning and continuous refinement of their surgical proficiency in the relentless pursuit of excellence.”
In the press release, Foot & Ankle International Editor in Chief Dr. Saltzman commented, “The goal of a surgeon is to always get better—and that can be measured in terms of clinical outcomes.”
Dr. Saltzman continued, “Each surgeon has the responsibility to review their own results rather than compare the number of cases they have done to some published paper with a conceptually flawed benchmark.”
