The Influence of Volume and Experience on Individual Surgical Performance A Systematic Review

Objective: To systematically review studies evaluating the influence of surgical experience on individual performance. Background: Experience, measured in case volume or years of practice, is recognized as a key driver of individual surgical performance, giving rise to a learning curve. However, this topic has not been reviewed at the cross-specialty level. Methods: MEDLINE, EMBASE, PsycINFO, AMED, and the Cochrane Database of Systematic Reviews were searched (from inception to February 2013). Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Ninety-one data points per study were extracted. Results: The search strategy yielded 6950 citations. Fifty-seven studies were eligible, including 1,061,913 cases and 35 procedure types, performed by 17,912 surgeons. Forty-five studies monitored case volume, and 6 studies measured experience as both case volume and years of practice. Of these 51 studies, 44 found that increased case volume was associated with significantly improved health outcomes. Several studies noted a plateau phase or maturation in the surgical learning curve. Acquisition of this phase was procedure specific and outcome specific, ranging from 25 to 750 procedures. Twelve studies assessed the impact of years of surgical practice, 11 of which found that increased years of experience was associated with significantly improved health outcomes. Two studies noted a plateau phase, where increases in years of experience were no longer associated with improvements in operative outcomes. Three studies identified performance deterioration after the plateau phase. Conclusions: Increasing surgical case volume and years of practice are associated with improved performance, in a procedure-specificmanner. Performance may deteriorate toward the end of a surgeon's career.