Practice and Proficiency: From the Airport to the Operating Room

by Tom Robertson

Executive Director, Vizient Research Institute

An important consequence of the COVID-19 pandemic and associated reductions in travel was the issue of pilot proficiency when airlines resumed normal operations. Commercial airline pilots were not able to simply get into their cars, drive to the airports and taxi toward the runway. An integral part of an airline pilot’s certification involves complying with a condition known as “recency.” 

To be certified for commercial flights, pilots must have completed at least three takeoffs and landings within the last 90 days; with at least one involving the airplane’s automatic landing system. To fly after dark, pilots also are required to have completed at least three nighttime flights within the last 90 days.  

In addition to these recency requirements, commercial airline pilots are checked for proficiency every six months. They are rated for a specific aircraft; an F-14 fighter pilot cannot jump into the cockpit of a Boeing 787 full of passengers. With a 175,000-pound airplane (40,000 pounds of which being highly combustible jet fuel) traveling 575 miles per hour, things can happen. As we stow our carry-on luggage in the overhead compartment and nestle into our seats, we don’t want to wonder whether the pilot does this sort of thing very often. 

Surgeons and jet pilots have at least two characteristics in common: confidence and courage. Pushing the throttle forward at the end of a runway and grasping a scalpel while standing over a seriously ill patient takes nerve. The surgeon has a plan—they know exactly what they’ll do immediately after making the first cut. Pilots know that the plane will lift off when their ground speed reaches what is known as “rotation.” As highly trained professionals, they each have the confidence and courage to undertake relatively risky procedures on a regular basis. 

And it is the very regularity of those undertakings that we all rely upon when we place our lives in their hands. Because another thing common to surgery and flying is that proficiency comes with repetition. The value of volume is not limited to surgeons but extends to surgical programs. The experience of the care teams before and especially after the procedure itself—and their ability to handle unexpected complications—increases the probability of favorable outcomes. 

Medical literature reviews, including one published in the National Library of Medicine, which is part of the National Institutes of Health, cite numerous studies linking surgical outcomes to the volume of procedures performed at a given hospital; a similar relationship between outcomes and individual surgeon volume has been known for nearly twenty years, as established in the New England Journal of Medicine in 2003. Those studies found that when surgical volumes fall below a proficiency threshold, the increased risk of adverse outcomes is statistically significant.  

Surgeons and surgical programs, like pilots, are subject to a “recency” effect. It is unsafe when too much time elapses between repetitions of a complicated task. An issue facing medicine in America is the prevalence of high-risk surgeries occurring in settings where volumes fall well below proficiency thresholds, resulting in excess complications and avoidable deaths. 

Using all-payer hospital discharge data from multiple states, an examination of surgical volumes across major metropolitan markets and within multihospital health systems uncovers a troubling discovery. In city after city—Miami, Houston, Pittsburgh, Baltimore, and Dallas—between 25% and nearly half of all lung resections among cancer patients occur in surgical programs with volumes below minimum proficiency thresholds as published in the medical literature. These are not remote rural geographies where a case could be made that a low-volume surgical alternative is better than no clinical capability at all. These are large urban markets where high-volume alternatives are within easy driving distance.  

Even more troubling is the proliferation of low-volume surgical programs within health systems in which high-volume alternatives are readily available. Our research commonly found health systems in which one or more programs performed hundreds of mitral valve replacements annually (well above the proficiency threshold of 40) while other programs in the same system performed fewer than ten. 

As part of the same study, we polled health system executives and physicians and asked whether they would go outside of their systems for high-risk procedures for themselves or family members if necessary to access a high-volume surgical program. Seventy-seven percent of executives and over 80% of physicians indicated that they would not choose a low-volume surgical program for themselves or their families. Despite scientific evidence in favor of concentrating high-risk procedures in high-volume settings and the overwhelming consensus among clinical and executive leaders when contemplating their own care, consolidation within health systems remains largely unfinished business. 

One reason commonly cited for the lack of clinical consolidation is the belief that patients prefer to have surgery—even high-risk surgery—close to home. As part of our most recent study, we asked a national sample of patients and potential patients whether they would be willing to travel for surgery if it meant a lower risk of adverse outcomes. Seventy-four percent of respondents indicated a willingness to drive at least two hours to a higher volume provider. That willingness to travel transcended both education and income. As it turns out, physicians, health care executives and patients all agree that given the choice between higher volume/lower risk and lower volume/higher risk, the decision is an easy one. 

When we think of averted airline disasters, we immediately remember U.S. Airways flight 1549 and Captain “Sully” Sullenberger landing the plane in the Hudson River, but such heroics are not at the heart of the relationship between repetition and proficiency. Sullenberger had never landed an airplane moments after a flock of geese knocked out both engines. The reason that airline travel is as safe as it is does not rely on ditching disabled planes on urban rivers…it requires the industry to get 87-ton airplanes off the ground and back down again safely roughly 10 million times each year with zero failures. That level of performance demands repetition. We count on it every time that we step onboard an airplane. When I stare up at the bright lights of an operating room, with my heart racing and the memory of just having kissed my wife goodbye fresh in my mind, I hope for nothing less. 

Sources: 

• Bauer H, Honselmann KC. Minimum Volume Standards in Surgery - Are We There Yet?. Visc Med. 2017;33(2):106-116. doi:10.1159/000456041 
• Birkmeyer J, Stukel T, Siewers A, et al. Surgeon Volume and Operative Mortality in the United States. New Engl J Med 2003;349:2117-2127. doi:10.1056/NEJMsa035205 
• Vizient Research Institute. Health Care as an Uncommon Good: In Search of a Path Forward. 2021. 
• All-payer state inpatient data sets for Pennsylvania, Florida, Maryland, and Texas. 2019.