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The influence of experience on complication rates
LETTERS TO THE EDITOR J Oral Maxillofac 45906,
Surg
1967
could potentially face a disadvantage in a malpractice claim solely because he or she may have had “less surgical experience” than another surgeon down the block, which one could argue increased the likelihood of a particular complication occurring. Stated another way, am I not practicing within the standard of care in my community if I only completed residency several months ago or have had fewer years of experience than most other oral surgeons? To meaningfully relate “experience of the surgeon” and rate of complications, one could suggest designing a study to include at least a large cross-section of training programs or, more ideally, a comparison including not just residents in training, but a large number of practicing surgeons with a continuum of years of experience.
THE INFLUENCE OF EXPERIENCE ON COMPLICATION RATES To the Editor:-This letter is in response to the article in the November 1986 issue of the Journal by Sisk et al. entitled “Complications Following Removal of Impacted Third Molars: The Role of the Experience of the Surgeon” (J Oral Maxillofac Surg 44:855, 1986). The authors
concluded that, based on comparative results of third molar surgery between residents and faculty at one institution, “. . . less experienced surgeons as a group have a significantly higher incidence of complications.” The overall incidence of complications was “four times greater in the resident-treated group than in the facultytreated group.” On first reading the article, the objectives and conclusions seemed clear and somewhat predictable, but I could not help but seriously question the methodology and, therefore, the true meaning of such a retrospective study. First, I wondered why oral surgery faculty would want to compare their performance to that of (their own) residents, who by nature are “students in training,” in order to reach conclusions regarding the role of such a massive entity as “experience of the surgeon.” Second, considering that only six months ago I, too, was still a resident in training, it is not surprising that my reaction to such a comparison would be somewhat disheartening. As a resident, I remembered our occasional friendly bantering with the attending staff such as “whether the ‘resident side’ or the ‘attending side’ swelled more after the last sagittal split” or “who had more dry sockets recently?” However, these asides were never serious or literally intended, nor would we ever have considered publishing such data. Perhaps even more significantly, the more I actually reflected on my recent training, the more I realized that the residents in my program had an exceedingly low rate of complications following third molar surgery and, in my honest estimation, not significantly different from that of our attending staff. Over the course of three years, I recall very few nerve dysesthesias among resident cases, a rare (almost nonexistent) occurrence of postoperative infection (despite our not routinely prescribing antibiotics), and an incidence of dry sockets that was, at worst, the same as that of our attendings (although they would probably take issue with the latter). The basic reason for this, I believe, is that we were well-trained at performing third molar surgery in a careful, prescribed, and aseptic manner. We did not even treat wisdom teeth (with rare exception) until our second year, after having already gained experience in routine exodontia, infection, and trauma at a busy city hospital. With all due respect, perhaps the disparity cited in this article by Sisk et al. is a reflection on one particular training program. I feel that the data from a study such as this cannot possibly be extrapolated to account for the large number of oral surgeons with a myriad of surgical experiences who are currently performing third molar surgery. Of further concern are the possible implications (i.e., medicolegal) that may negatively impact on our profession. I would not want to think that a surgeon
RICHARD A. MUFSON, DDS Miami, Florida
The author replies:-The 1979 N.I.H. Consensus Development Conference on the Removal of Third Molars recommended that research be undertaken to study the incidence of morbidity in third molar surgery. Suggested research areas were relationship to age and therapeutic approaches to prevention or control of pain, swelling, trismus, infection, and hemorrhage.’ It was during the collection and statistical analysis of data for our studies in these areas that we first noted, and then further analyzed, the differences in preoperative and postoperative morbidity that existed among surgeons in our program. This led to the report referred to by Dr. Mufson, as well as to our development of additional studies that we hope will develop techniques to reduce the incidence of surgical morbidity for all oral and maxillofacial surgeons. The editor of this journal, Dr. Laskin, in an editorial published following the 1979 Consensus Development Conference, alluded to the dichotomy between clinical impressions and scientific data.2 Dr. Mufson, in his anecdotal recollections of his residency experiences, has himself unfortunately fallen into the trap of reaching a conclusion without benefit of scientific documentation or objective clinical testing. Clinical research is vital to our profession. We encourage Dr. Mufson and others in private practice, as well as other residency programs, to contribute their scientific data to the literature on third molar surgery. As a new practitioner, Dr. Mufson is in the enviable position of being able to conduct a long-term prospective clinical study of his third molar patients. We look forward to his contributions to clinical research. ALLEN L. SISK, DDS Augusta, Georgia
References development conference for removal of third molars. J Oral Surg 38:235. 1980
I. NIH consensus
2. Laskin DM: A question of answers. J Oral Surg 38:485, 1980
906
Surg
1967
could potentially face a disadvantage in a malpractice claim solely because he or she may have had “less surgical experience” than another surgeon down the block, which one could argue increased the likelihood of a particular complication occurring. Stated another way, am I not practicing within the standard of care in my community if I only completed residency several months ago or have had fewer years of experience than most other oral surgeons? To meaningfully relate “experience of the surgeon” and rate of complications, one could suggest designing a study to include at least a large cross-section of training programs or, more ideally, a comparison including not just residents in training, but a large number of practicing surgeons with a continuum of years of experience.
THE INFLUENCE OF EXPERIENCE ON COMPLICATION RATES To the Editor:-This letter is in response to the article in the November 1986 issue of the Journal by Sisk et al. entitled “Complications Following Removal of Impacted Third Molars: The Role of the Experience of the Surgeon” (J Oral Maxillofac Surg 44:855, 1986). The authors
concluded that, based on comparative results of third molar surgery between residents and faculty at one institution, “. . . less experienced surgeons as a group have a significantly higher incidence of complications.” The overall incidence of complications was “four times greater in the resident-treated group than in the facultytreated group.” On first reading the article, the objectives and conclusions seemed clear and somewhat predictable, but I could not help but seriously question the methodology and, therefore, the true meaning of such a retrospective study. First, I wondered why oral surgery faculty would want to compare their performance to that of (their own) residents, who by nature are “students in training,” in order to reach conclusions regarding the role of such a massive entity as “experience of the surgeon.” Second, considering that only six months ago I, too, was still a resident in training, it is not surprising that my reaction to such a comparison would be somewhat disheartening. As a resident, I remembered our occasional friendly bantering with the attending staff such as “whether the ‘resident side’ or the ‘attending side’ swelled more after the last sagittal split” or “who had more dry sockets recently?” However, these asides were never serious or literally intended, nor would we ever have considered publishing such data. Perhaps even more significantly, the more I actually reflected on my recent training, the more I realized that the residents in my program had an exceedingly low rate of complications following third molar surgery and, in my honest estimation, not significantly different from that of our attending staff. Over the course of three years, I recall very few nerve dysesthesias among resident cases, a rare (almost nonexistent) occurrence of postoperative infection (despite our not routinely prescribing antibiotics), and an incidence of dry sockets that was, at worst, the same as that of our attendings (although they would probably take issue with the latter). The basic reason for this, I believe, is that we were well-trained at performing third molar surgery in a careful, prescribed, and aseptic manner. We did not even treat wisdom teeth (with rare exception) until our second year, after having already gained experience in routine exodontia, infection, and trauma at a busy city hospital. With all due respect, perhaps the disparity cited in this article by Sisk et al. is a reflection on one particular training program. I feel that the data from a study such as this cannot possibly be extrapolated to account for the large number of oral surgeons with a myriad of surgical experiences who are currently performing third molar surgery. Of further concern are the possible implications (i.e., medicolegal) that may negatively impact on our profession. I would not want to think that a surgeon
RICHARD A. MUFSON, DDS Miami, Florida
The author replies:-The 1979 N.I.H. Consensus Development Conference on the Removal of Third Molars recommended that research be undertaken to study the incidence of morbidity in third molar surgery. Suggested research areas were relationship to age and therapeutic approaches to prevention or control of pain, swelling, trismus, infection, and hemorrhage.’ It was during the collection and statistical analysis of data for our studies in these areas that we first noted, and then further analyzed, the differences in preoperative and postoperative morbidity that existed among surgeons in our program. This led to the report referred to by Dr. Mufson, as well as to our development of additional studies that we hope will develop techniques to reduce the incidence of surgical morbidity for all oral and maxillofacial surgeons. The editor of this journal, Dr. Laskin, in an editorial published following the 1979 Consensus Development Conference, alluded to the dichotomy between clinical impressions and scientific data.2 Dr. Mufson, in his anecdotal recollections of his residency experiences, has himself unfortunately fallen into the trap of reaching a conclusion without benefit of scientific documentation or objective clinical testing. Clinical research is vital to our profession. We encourage Dr. Mufson and others in private practice, as well as other residency programs, to contribute their scientific data to the literature on third molar surgery. As a new practitioner, Dr. Mufson is in the enviable position of being able to conduct a long-term prospective clinical study of his third molar patients. We look forward to his contributions to clinical research. ALLEN L. SISK, DDS Augusta, Georgia
References development conference for removal of third molars. J Oral Surg 38:235. 1980
I. NIH consensus
2. Laskin DM: A question of answers. J Oral Surg 38:485, 1980
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