To the Editor.—
I would like to make several comments about the article by Hannan et al.1 Of note was the conclusion that high-volume physicians have better outcomes than low-volume physicians. The statistical analyses are complex, and simple conclusions drawn from complicated statistics are risky. The final paragraph discusses whether high volumes are caused by referrals to hospitals and physicians with good outcomes and reputations. The authors call this the selective referral hypothesis: whether hospitals and physicians with good outcomes have learned to be proficient by performing high volumes of surgeries, the "practice makes perfect" hypothesis. This is a gross oversimplification and implies we have proved the point and that it must be one of these two reasons.Unfortunately, there are many variables that were not looked at. I would like to raise a few of these. One should ask if all of the low-volume operators are fully trained
Teitel ER. Surgeon Volume vs Hospital Volume: Which Matters More?. JAMA. 1990;263(11):1493. doi:10.1001/jama.1990.03440110054018
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