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.