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Invited Commentary
December 16, 2020

Peer Review and the Quest for Technical Excellence in Surgery—A Lesson in Self-awareness

Author Affiliations
  • 1Department of Surgery, University of Chicago, Chicago, Illinois
JAMA Surg. 2021;156(2):e205557. doi:10.1001/jamasurg.2020.5557

There is an old joke in surgery that if you ask a surgeon “who are the 3 greatest surgeons in the world?” he (usually a he) cannot name the other 2. From bacteria to humans, competition among species is a fundamental property that nature uses to maintain fitness (ie, reproductive success). For example, bacteria synchronize their behavior via a system of quorum sensing that allows them to behave as a cohesive social group.1,2 In this way, cooperative competition refines fitness so the rising tide of experience and results can raise all boats. So how do surgeons do this? Excellent training, meticulous attention to technique, and the continuous review of one’s results has certainly been the time-honored approach. However, the questions of whether this is enough and how physicians can be objective about their results in isolation remain. Chhabra et al3 ask an important question: Are there ways of refining one’s fitness as a surgeon so performance and results continue to improve in synch with experts in the field? In this issue of JAMA Surgery, a cohort study by this outstanding group of investigators provides yet another novel application of the use of video review as a mechanism to refine technique, which they link, for the first time, to the desired optimal result of an operation, in this case improved weight loss, less hemorrhage, and less gastroesophageal reflux disease after a sleeve gastrectomy. Results of this study are significant because of the rigor of the work, which found an association between technique, during what some might consider a simple operation, to highly undesirable results in all three areas: less weight loss, more gastroesophageal reflux disease, and an increased risk of hemorrhage. It is tempting to dismiss subtle steps in an operation as “good enough” with aphorisms such as “the enemy of good is perfect”; however, here we learn a powerful lesson: meticulous attention to technical details that have been defined by consensus to be important in outcome for a given operation does indeed make a difference. The finding in this study that technique is an important factor associated with outcomes independent of surgical skill reinforces the importance of peer-to-peer review (via video) as a feedback mechanism to refine fitness and synchronize our behavior. The most exciting part of this method is its positive effect on the surgeon, the program, and, most importantly, the patient.

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