Misusing the concept of a 'learning curve'

Finding

The evidence suggests that the acceptance of a learning curve muted the degree of concern that Drs. Odim, Giddins and Wiseman should have had when surgical nurses and anaesthetists voiced concerns about surgical results.

The question of a 'learning curve' needs to be placed into a proper context.

Neither Blanchard nor Bishop (the department heads responsible for the program at the relevant time), the cardiologist nor the surgeon gave appropriate consideration to the fact that junior surgeons (such as Odim) and newly established (or re-established) surgical teams experience a learning curve. This learning curve is a recognized fact. Indeed, it was precisely because of the concept of a learning curve that many witnesses expressed a concern that the Pediatric Cardiac Surgery Program at the Children's Hospital was not able to perform enough operations to allow team members to establish and maintain their skills at a high enough level.

To that extent, there is validity to the consideration of a learning curve for individuals and teams. However, the concept of a learning curve can be abused. There should be no allowance for a learning curve where patient safety is concerned or when analysing results of surgery. While witnesses before this Inquest said that they recognized that a learning curve has no place in determining the acceptability of poor surgical results, there was a noted tendency on the part of some, in defending the events of 1994, to point to what they considered similar 'results' at the start of Dr. Kim Duncan's career in Winnipeg. This was apparently used as a rationale for believing that there was no need to be alarmed about what was occurring in the Pediatric Cardiac Surgery Program in Winnipeg in the spring or fall of 1994. That was simply not an appropriate use of the concept of a learning curve.

The evidence does establish that surgeons and surgical teams have the potential to have higher morbidity and mortality rates in the early stages of their development. These rates are likely to be higher if the program in which they are functioning does not go through a carefully planned and initiated start-up, if it is not properly and closely monitored and if steps are not taken to identify and resolve problems and improve performance. That fact should have caused those in charge of the program to have taken two major steps before the start-up of the program in 1994.

First, an effort should have been made to ensure that an experienced person was in a position of authority in the program to provide guidance with respect to start-up issues that the program was inevitably going to face.

Secondly, those in charge of the program ought to have been careful to ensure that the new surgeon and the restarted program were closely monitored at least throughout the first year. Initial patient selection ought to have been restricted to those cases that promised the best results during the period of time that individual and team experience was gained. The evidence suggests that, unfortunately, few steps were taken to ensure that the program did not take on cases that were beyond the capabilities of either the surgeon or the team as a whole throughout the year. Those in charge of the program acted on the basis that poor surgical results would simply improve over time. That was simply not appropriate.

Blanchard and Bishop, the department heads responsible for the program at the relevant time, Giddins, the cardiologist, and Odim, the pediatric cardiac surgeon, all bear some responsibility in that they failed, individually and collectively, to ensure that the program was restarted on a carefully phased basis.