Sudip K. Sarker

Objective assessment of technical skills in surgery

In the past few years, considerable developments have been made in the objective assessment of technical proficiency of surgeons. Technical skills should be assessed during training, and various methods have been developed for this purpose Surgical competence entails a combination of knowledge, technical skills, decision making, communication skills, and leadership skills. Of these, dexterity or technical proficiency is considered to be of paramount importance among surgical trainees. The assessment of technical skills during training has been considered to be a form of quality assurance for the future.1 Typically surgical learning is based on an apprenticeship model. In this model the assessment of technical proficiency is the responsibility of the trainers. However, their assessment is largely subjective.2 Objective assessment is essential because deficiencies in training and performance are difficult to correct without objective feedback.3 The introduction of the Calman system in the United Kingdom, the implementation of the European Working Time Directive, and the financial pressures to increase productivity4 have reduced the opportunity to learn surgical skills in the operating theatre. Studies have shown that these changes have resulted in nearly halving the surgical case load that trainees are exposed to.5 Surgical proficiency must therefore be acquired in less time, with the risk that some surgeons may not be sufficiently skilled at the completion of training.6 This and increasing attention of the public and media on the performance of doctors have given rise to an interest in the development of robust methods of assessment of technical skills.7 We review the research in this field in the past decade. Our objectives are to explore all the available methods, establish their validity and reliability, and examine the possibility of using these methods on the basis of the available evidence. We collected information for this review from …

Systems Approaches to Surgical Quality and Safety: From Concept to Measurement

Objective:This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes. Summary Background Data:Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patients stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. Methods:Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an “operation profile” to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed.

Self-appraisal hierarchical task analysis of laparoscopic surgery performed by expert surgeons

BackgroundEvaluation of technical skill is notoriously difficult because of the subjectivity and time-consuming expert analysis. No ongoing evaluation scheme exists to assess the continuing competency of surgeons. This study examined whether surgeons’ self-assessment accurately reflects their actual surgical technique.MethodsHierarchical task analysis (HTA) of laparoscopic cholecystectomy was constructed. Ten expert surgeons were asked to modify the HTA for their own technique. The HTAs of these surgeons then were compared with their actual operations, which had been recorded and assessed by two observers.ResultsA total of 40 operations were assessed. All the gallbladders subjected to surgery were classified as grades 1 to 3. The mean interrater reliability for the two observers had a k value of 0.84 (p < 0.05), and the mean intrarater reliability between surgeons and observers had a k value of 0.79 (p < 0.05).ConclusionsSurgeons’ self-evaluation is accurate for technical skills aspects of their operations. This study demonstrates that self-appraisal using HTA is feasible, accurate, and practical. The authors aim to increase the numbers in their study and also to recruit residents.

Procedural performance in gastrointestinal endoscopy: An assessment and self-appraisal tool

AIMS Assessing endoscopic technical skills competency in a structured manner is a topical issue, in light of several workforce factors that may affect the training of future endoscopists. To date there has been little attempt to comprehensively assess both generic and specific technical skills in lower gastrointestinal endoscopies; the current study aimed to develop and validate a tool that can assess these varied skills. METHODS Hierarchical task analyses of generic and specific technical skills were constructed on flexible sigmoidoscopy and colonoscopy after expert panel discussions. Generic technical skills are subtasks (eg, movements of the control wheel) that allow the endoscopist to complete a main task (specific technical skills), for example, reaching the cecum. Weighted Likert scales were then constructed individually for generic and specific technical skills for each procedure. Two observers assessed each procedure independently. RESULTS A total of 135 endoscopic procedures were performed by 9 consultants and 12 registrars. Mean inter-rater reliability Cronbach alphas were .83 and .80, P < or =.05, for generic and specific skills, respectively, for each procedure. Construct validity results using analysis of variance (ANOVA) for consultants and trainees were significant for each procedure, P = .005, P = .003 for generic, and P = .012, P = .004 for specific technical skills. CONCLUSIONS This new assessment/self-appraisal tool for lower gastrointestinal endoscopies seems to have face, content, concurrent, and construct validities. The tool has the possibility of being used in training and self-appraisal. We aim to modify and apply this tool to other endoscopic procedures in the future, such as endoscopic retrograde cholangiopancreatography (ERCP), endoluminal and transluminal procedures.

Technical skills errors in laparoscopic cholecystectomy by expert surgeons

Background:Performing laparoscopic surgery involves a complex cascade of cognitive skills, which may inherently have a constant technical error rate. We assess generic and specific minor and major error rates in laparoscopic cholecystectomies (LCs) performed by consultant surgeons.Methods:Checklists of generic (11) and specific technical minor (six) and major events (eight) were devised for LCs. Two experienced surgeons assessed each full-length operation blindly and independently.Results:A total of 37 LCs were performed by eight consultants. There were no major intraoperative or postoperative complications. Mean inter-rater reliability was κ = 0.91 (range 0.80–0.98) for each of the error categories. Error rates were generic (27/407) 6.6%, minor (59/222) 26.6%, and major (8/296) 2.7%, respectively. There was a significant statistical difference between the minor error group and the other groups, p ≤ 0.05.Conclusions:Performing laparoscopic surgery may always have a background technical error rate. Our present study demonstrates a migration of surgical technical errors in expert laparoscopic surgeons. The surgeons migrate technically when they execute a high rate of procedure-specific minor errors. However, when it comes to the major fundamental aspects of the operation, they dynamically adapt and migrate away from performing major technical errors. We aim to continue the study to increase cases, assess trainees as well, and also explore other factors that may affect the surgeon when executing surgical technical tasks.

Validation of open inguinal hernia repair simulation model: a randomized controlled educational trial

BACKGROUND A hernia repair open surgical simulation computer software was developed at Imperial College London. A randomized controlled educational trial was conducted to investigate the benefit of the simulation on the development of procedural knowledge. METHODS Medical students in their clinical years were invited to participate in the trial. Students were block randomized to 4 groups: G1--Interactive Simulation; G2--Non-interactive Simulation; G3--Video Tutorial; G4--Control. On completion, they were objectively assessed on their ability to recall the tasks involved in an open inguinal hernia repair in the form of a multiple choice question (MCQ) and a simulated discussion with a consultant surgeon. RESULTS Fifty-six students completed the study. Each arm carries similar baseline scores (pre-intervention MCQ) with means 43.33, 38.92, 38.33, and 39.57 in G1 to G4, respectively. MCQ score improvements and final assessment scores proved better in the intervention groups (1, 2, and 3) compared to controls. CONCLUSION The interactive simulation has shown an objective benefit in teaching medical students the anatomical and procedural knowledge in performing an open inguinal hernia repair.