Surgeons' non-technical skills

A Prospective Study to Assess the Relationship Between Nontechnical Skills for Surgeons (NOTSS) and Patient Outcomes

BACKGROUND

Effective technical and nontechnical skills are necessary for surgeons to provide optimal patient care. The aim of this study was to assess the relationship between Nontechnical Skills for Surgeons (NOTSS) and postoperative outcomes among general surgery patients.

METHOD

This prospective observational study was conducted at a single, large, urban, academic hospital in the USA from February to September 2022. Two raters (an observer and a nurse) assessed each participating surgeon during 3 to 5 different operations. Patient outcome data were collected from the Illinois Surgical Quality Improvement Collaborative (ISQIC) database. We used the American College of Surgeons National Quality Improvement Program (ACS NSQIP) method to calculate risk-adjusted complications. Robust linear regression models were used to assess the association between surgeons' nontechnical skills and risk-adjusted postoperative complications.

RESULTS

Of the 45 surgeons who were observed in the study, 25 (55.5%) had patient outcome data captured by the ISQIC database. The adjusted analysis found that for every unit increase in the NOTSS score, there was a significant 5.1 (95% CI: -8.1; -2.0,p = 0.003), decrease in the adjusted risk of any postoperative complication, a significant 1.1 (95% CI: -1.8; -0.2, p = 0.01) decrease in the adjusted risk of mortality, and significant 1.1 (95% CI: -1.9; -0.4, p = 0.005) decrease in adjusted risks of returning to the operating room.

CONCLUSION

Higher surgeons' nontechnical skills scores were associated with a decreased risk-adjusted rate of any postoperative complication, mortality, and return to the operating room. Strategies to improve postoperative patient outcomes should include the improvement of surgeons' nontechnical skills.

Nontechnical Skills Assessment in Acute Care Trauma Simulations: A Mixed Methods Approach Using Eye Tracking and Behavioral Marker Systems

INTRODUCTION

The condition of trauma patients and the urgent need for timely resuscitation present unique challenges to trauma teams. These difficulties are exacerbated for military trauma teams in combat environments. Consequently, there is a need for continued improvement of nontechnical skills (NTS) training for trauma teams. However, current approaches to NTS assessment rely on subjective ratings, which can introduce bias. Accordingly, objective methods of NTS evaluation are needed. Eye-tracking (ET) methods have been applied to studying communication, situation awareness, and leadership in many health care settings, and could be applied to studying physicians' NTS during trauma situations. In this study, we aimed to assess the relationship between trauma team leaders' objective gaze patterns and subjective expert NTS ratings during patient care simulations.

MATERIALS AND METHODS

After Institutional Review Board approval, 9 trauma teams from first-year post-graduate general surgery and emergency medicine residents were recruited to participate in 1 of 2 trauma simulations (a difficult airway case and a multi-patient trauma). Each scenario lasted approximately 15 minutes. All team leaders wore a mobile ET system to evaluate gaze metrics-time to first fixation (TTFF), average fixation duration (AFD), and total percentage of the scenario (TPS) focused on Areas of Interest (AOI), which included patient, care team, diagnostic equipment, and patient care equipment. Trained faculty raters completed the Non-Technical Skills for Surgeons (NOTSS) assessment tool and the Trauma Non-Technical Skills (T-NOTECHS) scale. One-way analysis of variance, Kruskal-Wallis, and appropriate post-hoc pairwise comparison tests were run to assess differences between ET metrics across AOI groups. Spearman's Rho tests were used to assess correlations between ET and subjective NTS ratings.

RESULTS

Compared to other NTS domains, trauma teams scored relatively poorly on communication across both T-NOTECHS (3.29$ \pm $0.61, maximum = 5) and NOTSS (2.87$ \pm $0.66, maximum = 4). We found significant differences in trauma team leaders' TTFF between teammates and the patient (Team: 1.56 vs Patient: 29.82 seconds, P < .001). TTFF on the diagnostic equipment was negatively correlated (P < .05) to multiple measures of subjective NTS assessments. There were no significant differences in AFD between AOIs, and AFD on teammates was positively correlated (P < .05) to communication and teamwork. There were significant differences in TPS across most AOI pairs (P < .05), and the average TPS fixated was highest on the patient (32%). Finally, there were several significant correlations between additional ET and NTS metrics.

CONCLUSIONS

This study utilized a mixed methods approach to assess trauma team leaders' NTS in simulated acute care trauma simulations. Our results provide several objective insights into trauma team leaders' NTS behaviors during patient care simulations. Such objective insights provide a more comprehensive understanding of NTS behaviors and can be leveraged to guide NTS training of trauma physicians in the future. More studies are needed to apply these methods to capture NTS from a larger sample of teams in both simulated and real trauma environments.

What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey

INTRODUCTION

The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests.

METHODS

A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform.

RESULTS

Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks.

CONCLUSIONS

This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

A scoping review of assessment methods of competence of general surgical trainees

BACKGROUND

Only rigorous evaluation of competence will result in the production of safe surgeons that are able to provide the best care for patients. The development of competency-based assessment should ultimately be evidence driven.

OBJECTIVES

Explore the volume of existing evidence pertaining to the different objective assessment methods reported in the literature.

ELIGIBILITY CRITERIA

Studies describing objective assessment of postgraduate general surgical trainees within the last 20 years.

SOURCES OF EVIDENCE

PubMed, Ovid Medline and Web of Sciences.

CHARTING METHODS

A data chart proforma was designed and data were extracted into tables. Basic numerical analysis of extracted data and narrative synthesis of charted data.

RESULTS

A total of 343 papers were reviewed. 26 were eligible for inclusion. 92% of articles were published from 2008 onwards. 50% have been published in the last five years. The articles originated from 6 different countries, predominantly the United Kingdom (42%), followed by the United States of America (38%). In addition, a small number were published from Canada (8%), Japan (4%), Germany (4%) and Australia (4%). UK publications were predominantly between 2008 and 2014 while the USA had a later predominance between 2015 and 2018. 42% were based on quantitative methodology, 27% had a qualitative approach while 31% had mixed analysis. There were sixteen assessment methods presented. The most common type of assessment was Objective Structured Assessments (27%), which included Objective Structured Assessment of Technical Skill (OSATS) (23%) and Objective Structured Assessment of Non-Technical Skill (4%). Procedure Based Assessment (PBA) (23%) and Entrustability Scales (23%) were also prevalent.

CONCLUSIONS

This scoping review has identified a range of different assessment methods. The assessment methods with a higher volume and level of supporting evidence were OSATS, PBAs and Entrustability Scales. There was a lower volume and level of supporting evidence found within this review for the remaining assessment methods.

A distractions capture tool for cardiac surgery and lung transplantation: impact on outcomes

OBJECTIVES

Surgical distractions are associated with worse patient outcomes. Lung transplantation and cardiac surgery's multi-disciplinary nature, and their inherent complexities render them more vulnerable to distractions. We aim to use a novel distractions capture tool to evaluate the severity of distractions during cardiac surgery (CS) and lung transplantation (LTx) and assess its impact on post-operative complications.

METHODS

A prospective 'blinded' study was undertaken by direct observation of distractions during CS and LTx. Events were identified using the Imperial College Error Capture tool (ICECAP). Number and severity of distractions were correlated with post-operative outcomes (ICU & hospital stay, bleeding and anastomotic complications).

RESULTS

In LTx, we observed 2059 distractions within 287 h across 41 surgeries. In CS, we observed 1089 distractions within 192 h across 62 surgeries. Surgeons were consciously aware of 19.2% (LTx) and 21.3% (CS) of recorded events. Distractions consisted of procedure-independent pressures (61% LTx vs 56% CS), equipment problems (15% LTx vs 23%CS), communication (12% LTx vs 12% CS), technical problems or patient safety concerns (12% LTx vs 9% CS). In CS, 91% of procedure-independent pressures were non-operative distractions whilst LTx recorded 83%. Staff absences at a critical moment of surgery were recorded at 9% (LTx) and 7% (CS). The number and severity of distractions correlated with bleeding (CS p < 0.001, LTx p < 0.01), prolonged ICU stay (CS p = 0.002, LTx p = 0.002), hospital stay (CS p < 0.001) and anastomotic complications(LTx p < 0.03).

CONCLUSIONS

ICECAP as a novel surgical distractions capture tool was effective & applicable to both elective cardiac and urgent transplant surgeries. Surgeons were unaware of a large number of distractions & interruptions. Distractions were associated with longer ICU stay and higher rate of bleeding.

Automatic Assessment of Procedural Skills Based on the Surgical Workflow Analysis Derived from Speech and Video

Automatic surgical workflow analysis (SWA) plays an important role in the modelling of surgical processes. Current automatic approaches for SWA use videos (with accuracies varying from 0.8 and 0.9), but they do not incorporate speech (inherently linked to the ongoing cognitive process). The approach followed in this study uses both video and speech to classify the phases of laparoscopic cholecystectomy, based on neural networks and machine learning. The automatic application implemented in this study uses this information to calculate the total time spent in surgery, the time spent in each phase, the number of occurrences, the minimal, maximal and average time whenever there is more than one occurrence, the timeline of the surgery and the transition probability between phases. This information can be used as an assessment method for surgical procedural skills.

Why non-technical skills matter in surgery. New paradigms for surgical leaders

The surgical literature is paying more and more attention to the topic of soft or non-technical skills (NTS), defined as those cognitive and social skills that characterize high-performing individuals and teams. NTS are essential in supporting surgeons in dealing with unexpected situations. During the COVID-19 pandemic, NTS have been considered crucial in defining situation awareness, enhancing decision making, communicating among groups and teams, and fostering leadership. With a "looking back and planning forward" approach, the current perspective aims at deepening the contribution of NTS for surgeons to deal with the unexpected challenges posed by the COVID crisis, surgical emergencies, the introduction of new technologies in clinical practice, to understand how such skills may help shape the surgical leaders of the future.

Intraoperative Assessment of Non-Technical Skills for Surgeons (NOTSS) and Qualitative Description of their Effects on Intraoperative Performance

OBJECTIVE

The aims of this study were (1) to evaluate the feasibility of using the Non-Technical Skills for Surgeons (NOTSS) rating tool in assessing surgeons' non-technical skills behaviors in live operations, and (2) to describe the effect of NOTSS on intraoperative performance.

SETTING DESIGN

This study was conducted in an academic hospital in North America. Two observers independently conducted direct non-participant observations using the NOTSS rating tool to assess non-technical skills, and to document examples of effective or ineffective non-technical skills behaviors. Observers took field notes to document non-technical skill gaps that were not captured by the NOTSS rating tool, and situations or scenarios that presented challenges for accurate assessment. Interclass correlation estimates and 95% confidence intervals were calculated to assess the validity of the NOTSS rating tool. Deductive thematic qualitative data analysis was used for field notes and NOTSS behavior descriptions.

PARTICIPANTS

Participants were general surgeons performing either minimally invasive (robotic assisted or laparoscopic surgery), or open procedures.

RESULTS

We observed 18 surgeries, involving 6 surgeons, 11 residents and one fellow resulting in 37 hours of direct observations. The mean NOTSS score was 3.8 (SD 0.41) for situation awareness, 3.75 (SD 0.47) for decision-making, 3.71 (SD 0.39) for communication and teamwork, and 3.76 (SD 0.38) for leadership. The inter-rater reliability ranged between 0.65 and 0.80 for each NOTSS categories. The observers documented examples of effective non-technical skills behaviors and examples of behaviors that need improvement. Furthermore, we described the effect of each observed behavior on intraoperative performance. One challenge to NOTSS use in live surgery was that observers had to infer situation awareness, decision-making, and coping with pressure as these were not easily observed without attending surgeons articulating their underlying thought process.

CONCLUSION

The use of the NOTSS tool in live surgery is a valid and practical tool to document observed behaviors and their effect on intraoperative performance in order to provide constructive feedback to surgeons. One notable limitation is that without specific articulation by the surgeon of their underlying thought process the observer must infer specific elements. By documenting specific real-world events with high inter-rater reliability and adequate surgeon score variation the process can be used to provide useful feedback for improvement.

Interprofessional differences in preoperative planning—the individualist surgeon

Background

Perioperative processes have a great impact on the quality of surgery. In a high-risk surrounding, proper planning and communication is of upmost importance. We have identified other professions next to surgery with comparable circumstances and conducted a survey to elaborate on the impact of perioperative processes.

Objective

To identify standards in preoperative planning in high-risk professions and determine possible shortcomings in surgical practice.

Methods

Two surveys were constructed and distributed to surgeons, mountain guides, and soldiers. Questions were designed to investigate preoperative planning behavior and compare the different professions.

Results

Nearly every participant (97%) agreed to the fact that preoperative planning helps to avoid complications. Most surgeons agreed that the preoperative and postoperative phase of care had the greatest ability to improve overall quality of care. The opinions about planning were divided. The minority of surgeons agreed to the importance of sharing a plan preoperatively. Soldiers were the profession with the highest rate of plan sharing.

Conclusion

The readiness to communicate varies between professions and is lowest for surgeons. Missing standardization of procedures and the surgeon’s ego might be explanations for this behavior. Interventions to overcome this shortcoming, like the preoperative team timeout, have already been implemented but further improvements are needed.

Integrative Review of Non-Technical Skills Frameworks to Apply for Air Medical Transfer of Pregnant Women

OBJECTIVE

To identify the most suitable non-technical skills framework to adapt and apply to the air medical transfer of pregnant women.

DATA SOURCES

Embase, PsycINFO, PubMed, MEDLINE, Web of Science, CINAHL, Science Direct, and Google Scholar.

STUDY SELECTION

We retrieved potentially relevant articles using a predefined combination of keywords extended with truncation and Boolean operators. Database and manual reference searches yielded 569 peer-reviewed articles. We included articles if they presented empirical data and described non-technical or cognitive competency skills frameworks for health care professionals. We discussed any ambiguities regarding inclusion, and they were resolved by consensus. We retained 71 full-text articles for final review.

DATA EXTRACTION

We coded extracted data under four criteria: non-technical skill categories, context of use, psychometric properties, and rating system. We generated descriptive summary tables of the characteristics of existing non-technical skills frameworks based on publication year, method of development, clinical setting, clinical specialty, routine/crisis-based performance, and team/individual performance.

DATA SYNTHESIS

We identified 42 non-technical skills frameworks from a variety of health care settings. We critically examined context of use and how use in various clinical settings may align with air transfers of pregnant women. Our findings illustrate the importance of team-based and routine performance rather than crisis-focused skills. Maintaining situational awareness throughout all stages of the transfer and communicating effectively with team members, the pregnant woman, and her partner are skills that are particularly important to ensure good outcomes.

CONCLUSION

We selected the Global Assessment of Obstetric Team Performance as the most suitable non-technical skills framework to adapt to the clinical setting of air medical transfer of pregnant women. We considered the clinical specialty, specific non-technical skills required in the setting, the framework's properties, and the requirement to focus on routine team performance.

Learning NOTSS While Tying Knots: Integrating the Nontechnical Skills for Surgeons Course With Technical Surgical Skills Training, A Mixed Methods Study

Objective

The aims of this study were to describe the process of integrating 2 established training programs, Nontechnical skills for surgeons, and a traditional essential surgical skills course and to measure the impact of this integrated course on the behaviors of interprofessional surgical teams in Rwandan district hospitals.

Background

Surgical errors and resulting adverse events are due to variability in both technical and nontechnical surgical skills. Providing technical and nontechnical skills training to the perioperative team may enhance the learning of both of these skills and promote safe intraoperative patient care.

Methods

A quality improvement framework guided the process of integrating essential surgical skills and nontechnical skills into a single training program for surgical teams. The resulting 2-day training program was delivered to 68-person teams from 17 hospitals. Nontechnical skills for surgeons was taught through didactics and in the operating room, where preoperative briefing, intraoperative interactions, and postoperative debriefing were used as essential and nontechnical skills teaching moments. Postcourse surveys, follow-up interviews, focus groups, and direct observation of participants in the operating room were conducted to assess how participants implemented the knowledge and skills from the training into practice.

Results

Ninety-seven percent of the participants reported that they were satisfied with the course. Follow-up participant interviews and focus groups reported that the course helped them to improve their preoperative planning, intraoperative communication, decision-making, and postoperative debriefing.

Conclusions

It is possible to implement an integrated essential surgical skills and nontechnical skills training course. Integrating nontechnical skills into essential surgical skills courses may enhance learning of these skills.

Assessment of surgeon communication skills from the patient perspective: A national evaluation using the Communication Assessment Tool

OBJECTIVE

The Communication Assessment Tool (CAT) has previously been translated and adapted to the Italian context. This national study aimed to validate the CAT and evaluate communication skills of practicing surgeons from the patient perspective.

METHODS

CAT consists of 14 items associated with a 5-point scale (5 = excellent); results are reported as the percent of ''excellent'' scores. It was administered to 920 consenting outpatients aged 18-84 in 26 Italian surgical departments.

RESULTS

The largest age group was 45-64 (43.8%); 52.2% of the sample was male. Scores ranged from 44.6% to 66.6% excellent. The highest-scoring items were "Treated me with respect" (66.6%), "Gave me as much information as I wanted" (66.3%) and "Talked in terms I could understand" (66.0%); the lowest was "Encouraged me to ask questions" (44.6%). Significant differences were associated with age (18-24 year old patients exhibited the lowest scores) and geographical location (Northern Italy had the highest scores).

CONCLUSION

CAT is a valid tool for measuring communication in surgical settings.

PRACTICE IMPLICATIONS

Results suggest that expectations of young people for communication in surgical settings are not being met. While there is room to improve communication skills of surgeons across Italy, patients highlighted the greatest need in the Central and Southern regions.

OUP accepted manuscript

Background

Human factors (HF) integration can improve patient safety in the operating room (OR), but the depth of current knowledge remains unknown. This study aimed to explore the content of HF training for the operative environment.

Methods

We searched six bibliographic databases for studies describing HF interventions for the OR. Skills taught were classified using the Chartered Institute of Ergonomics and Human Factors (CIEHF) framework, consisting of 67 knowledge areas belonging to five categories: psychology; people and systems; methods and tools; anatomy and physiology; and work environment.

Results

Of 1851 results, 28 studies were included, representing 27 unique interventions. HF training was mostly delivered to interdisciplinary groups (n = 19; 70 per cent) of surgeons (n = 16; 59 per cent), nurses (n = 15; 56 per cent), and postgraduate surgical trainees (n = 11; 41 per cent). Interactive methods (multimedia, simulation) were used for teaching in all studies. Of the CIEHF knowledge areas, all 27 interventions taught ‘behaviours and attitudes’ (psychology) and ‘team work’ (people and systems). Other skills included ‘communication’ (n = 25; 93 per cent), ‘situation awareness’ (n = 23; 85 per cent), and ‘leadership’ (n = 20; 74 per cent). Anatomy and physiology were taught by one intervention, while none taught knowledge areas under work environment.

Conclusion

Expanding HF education requires a broader inclusion of the entirety of sociotechnical factors such as contributions of the work environment, technology, and broader organizational culture on OR safety to a wider range of stakeholders.

Virtual non-technical skills assessment training is an effective, scalable approach for novice raters

OBJECTIVES

The COVID-19 pandemic has forced a creative transition to virtual platforms due to physical distancing and travel restrictions. We designed and tested a highly scalable virtual training curriculum for novice raters using the Oxford NOTECHS non-technical skills rating system.

DESIGN

A three-day training course comprising virtual didactics, virtually facilitated simulations, and independent live observations was implemented. NOTECHS scores were submitted for eleven standardized video simulations and four live operations. Intraclass correlation coefficients (ICCs) were calculated for total NOTECHS scores and subcomponent scores. Raters previously trained in-person with the same standardized videos served as a comparator group for equivalence testing.

SETTING

All study activities were conducted in a large academic tertiary referral center in Singapore as part of an ongoing surgical safety initiative.

PARTICIPANTS

Seven staff members underwent training (three virtually and four in-person).  None had prior surgical experience or non-technical skills assessment training.

RESULTS

ICCs for total NOTECHS scores were 0.85 (95% CI, 0.73-0.98) for virtually trained raters and 0.83 for those trained in-person (95% CI, 0.68-0.99).  Scores were equivalent between groups within a 10% margin.

CONCLUSIONS

Non-technical skills assessment can be reliably taught in a highly scalable virtual format. Virtual NOTECHS training is a valuable tool for educational and quality improvement initiatives during the COVID-19 pandemic and for centers that lack ready access to onsite non-technical skills training expertise.

How can surgical skills in laparoscopic colon surgery be objectively assessed?-a scoping review

Background

In laparoscopic colorectal surgery, higher technical skills have been associated with improved patient outcome. With the growing interest in laparoscopic techniques, pressure on surgeons and certifying bodies is mounting to ensure that operative procedures are performed safely and efficiently. The aim of the present review was to comprehensively identify tools for skill assessment in laparoscopic colon surgery and to assess their validity as reported in the literature.

Methods

A systematic search was conducted in EMBASE and PubMed/MEDLINE in May 2021 to identify studies examining technical skills assessment tools in laparoscopic colon surgery. Available information on validity evidence (content, response process, internal structure, relation to other variables, and consequences) was evaluated for all included tools.

Results

Fourteen assessment tools were identified, of which most were procedure-specific and video-based. Most tools reported moderate validity evidence. Commonly not reported were rater training, assessment correlation with variables other than training level, and validity reproducibility and reliability in external educational settings.

Conclusion

The results of this review show that several tools are available for evaluation of laparoscopic colon cancer surgery, but few authors present substantial validity for tool development and use. As we move towards the implementation of new techniques in laparoscopic colon surgery, it is imperative to establish validity before surgical skill assessment tools can be applied to new procedures and settings. Therefore, future studies ought to examine different aspects of tool validity, especially correlation with other variables, such as patient morbidity and pathological reports, which impact patient survival.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08914-z.

Surgeons Are Not Pilots: Is the Aviation Safety Paradigm Relevant to Modern Surgical Practice?

Error in surgery is common, although not always consequential. Surgical outcomes are often compared to safety data from commercial aviation. This industry's performance is frequently referenced as an example of high-reliability that should be reproduced in clinical practice. Consequently, the aviation-surgery analogy forms the conceptual framework for much patient safety research, advocating for the translation of aviation safety tools to the healthcare setting. Nevertheless, overuse or incorrect application of this paradigm can be misleading and may result in ineffective quality improvement interventions. This article discusses the validity and relevance of the aviation-surgery comparison, providing the necessary context to improve its application at the bedside. It addresses technical and human factors training, as well as more novel performance domains such as professional culture and optimization of operators' condition. These are used to determine whether the aviation-surgery analogy is a valuable source of cross-professional learning or simply another safety cliché.

Safety with Innovation in Colon and Rectal Robotic Surgery

Robotic colorectal surgery has been touted as a possible way to overcome the limitations of laparoscopic surgery and has shown promise in rectal resections, thus shifting traditional open surgeons to a minimally invasive approach. The safety, efficacy, and learning curve have been established for most colorectal applications. With this and a robust sales and marketing model, utilization of the robot for colorectal surgery continues to grow steadily. However, this disruptive technology still requires standards for training, privileging and credentialing, and safe implementation into clinical practice.

Understanding Barriers and Facilitators to Behavior Change After Implementation of an Interdisciplinary Surgical Non-Technical Skills Training Program in Rwanda

OBJECTIVE

Nontechnical skills, such as situation awareness, decision making, leadership, communication, and teamwork play a crucial role on the quality of care and patient safety in the operating room (OR). In our previous work, we developed an interdisciplinary training program, based on the NOTSS (Non-Technical Skills for Surgeons) taxonomy. The aim of this study was to understand the challenges faced by Rwandan surgical providers, who had undergone NOTSS training, to apply these nontechnical skills during subsequent operative surgery.

SETTING DESIGN

A sequential exploratory mixed method study design was used to assess how participants who took the NOTSS in Rwanda applied nontechnical skills in surgical care delivery. The qualitative phase of this study deployed a constructivist grounded theory approach. Findings from the qualitative phase were used to build a quantitative survey tool that explored themes that emerged from the first phase.

PARTICIPANTS

Participants were nurses and resident from the departments of Surgery, Anesthesia, Obstetric, and Gynecology, from the University of Rwanda who attended the NOTSS course in March 2018.

RESULTS

A total of 25 participants and 49 participants were respectively enrolled in the qualitative phase and quantitative phase. Participants noted that nontechnical skills implementation in clinical practice was facilitated by working with other personnel also trained in NOTSS, anticipation, and preparation ahead of the time; while lack of interdisciplinary communication, hierarchy, work overload, and an inconsistently changing environment compromised nontechnical skills implementation. Nontechnical skills were useful both inside and outside the operating. Participants reported that nontechnical skills implementation resulted in improved team dynamics, safer patient care, and empowerment.

CONCLUSION

Surgical care providers who took the NOTSS course subsequently implemented nontechnical skills both inside and outside of the OR. Human and system-based factors affected the implementation of nontechnical skills in the clinical setting.

Surgical Teams' Attitudes About Surgical Safety and the Surgical Safety Checklist at 10 Years: A Multinational Survey

To assess health care professionals' attitudes on the Surgical Safety Checklist ("the Checklist") in resource-rich health systems and provide insights on strategies for optimizing Checklist use.

Background

In use for over a decade, the Checklist is a safety instrument aimed at improving operating room communication, teamwork, and evidence-based safety practices.

Methods

An online survey was sent to surgeons, nurses, and anesthesiologists in 5 high-income countries (Canada, the United States, the United Kingdom, Australia, and New Zealand). Survey results were analyzed using SPSS.

Results

A total of 2032 health care professionals completed the survey. Of these respondents, 47.6% were nurses, 70.5% were women, 65.1% were from the United States, and 50.0% had 20 years of experience or more in their role. Most respondents felt the Checklist positively impacted patient safety (70.9%), team communication (73.1%), and teamwork (58.9%). Only 50.3% of respondents were satisfied their team's use of the Checklist, and only 47.5% reported team members stopping to fully participate in the process. More nurses lacked confidence regarding their role in the Checklist process than surgeons and anesthesiologists combined (8.9% vs 4.3%). Fewer surgeons and anesthesiologists than nurses felt they received adequate training on the Checklist's use (57.8% vs 76.7%).

Conclusions

While most respondents perceive the Checklist as enhancing patient safety, not all surgical team members are actively engaging with its use. To enhance buy-in and meaningful use of the Checklist, health systems should provide more training on the Checklist with respect to its purpose and strengthening teamwork.

Teaching and Evaluating Nontechnical Skills for General Surgery

Surgical training programs have long used quantitative measures of knowledge, as well as subjective evaluation of technical skills, to define the competence of trainees. However, a growing body of literature has shown the importance of nontechnical surgical skills as vital components of quality surgical care. Institutions must train nontechnical surgical skills, including leadership, communication, teamwork, situational awareness, and decision making, and incorporate these attributes into their evaluative processes to maximally enhance surgical performance at every career stage.

[Multimodal training concept for temporal bone surgery]

BACKGROUND

Surgical training is increasingly supported by the use of simulators. For temporal bone surgery, shown here by means of mastoidectomy, there are other training models besides cadaver specimens, such as artificial temporal bones or computer-based simulators.

OBJECTIVES

A structured training concept was created which integrates different training methods of mastoidectomy with regard to effectiveness and current learning theory in education.

METHOD

A selective literature research was conducted to compare learning-theoretical findings and the availability and effectiveness of currently existing training models.

RESULTS

To acquire surgical skills, a stepwise approach is suggested. Depending on the progress with computer-based simulation, plastic or native temporal bones should be used. To achieve a plateau of the learning curve, approximately 25 semi-autonomous preparations are recommended. Different 'Objective Structured Assessments of Technical Skills' (OSATS) are implemented to assess the learning progress at different levels.

DISCUSSION

Simulation-based training is recommended until an adequate learning curve plateau is achieved. This is reasonable for patient safety, based on limited accessibility of human cadaveric temporal bones but also by findings of the learning theory.

CONCLUSION

The curriculum integrates different training models of mastoidectomy and OSATS into an overall concept. The training plan has to be continuously adapted to new findings and technical developments.

Gathering Validity Evidence to Adapt the Non-technical Skills for Surgeons (NOTSS) Assessment Tool to the United States Context

BACKGROUND

Nontechnical skills are of increasing focus for safe and effective performance in the operating room. Assessment tools have been developed in Europe, Africa, and Asia but not adapted to the unique aspects of surgical delivery in the United States. Our objective was to use the Non-Technical Skills for Surgeons (NOTSS) assessment tool as a basis to establish consensus on essential nontechnical skills for surgical trainees and practicing surgeons in the U.S surgical context.

STUDY DESIGN

A mixed-methods research design was used in the form of a modified Delphi process to build consensus on essential NOTSS. A panel of surgical experts from hospitals across the U.S used this iterative process in 4 rounds to generate, rate, and classify behaviors. The primary outcome was consensus on behaviors as being essential for surgeons to achieve the best patient outcomes in the operating room, with a median rating of ≥6 on a 7-point scale for inclusion.

RESULTS

A total of 10 surgical experts participated. One hundred and thirty eight behaviors were generated in Round 1, and reduced to 100 behaviors in Rounds 2 and 3 based on application of inclusion criteria. The final skill list consisted of behaviors in Situation Awareness (n = 26), Decision Making (n = 18), Teamwork (n = 25), and Leadership (n = 31). No additional NOTSS categories or elements emerged from the analysis. In Round 4, all 100 behaviors were successfully grouped into 12 nontechnical skills elements. Labels and definitions were reworded to reflect the U.S. context, and an appropriate assessment scale was selected.

CONCLUSIONS

A panel of surgical experts from across the U.S. reached consensus on the essential NOTSS to achieve the best patient outcomes in the operating room. These behaviors form an empirical basis for the first context-specific nontechnical skills assessment and training tool for practicing surgeons in the U.S.

Stress and resident interdisciplinary team performance: Results of a pilot trauma simulation program

BACKGROUND

Excessive stress negatively impacts surgical residents' technical performance. The effect of stress on trainee nontechnical skills, however, is less well studied. Given that nontechnical skills are known to impact clinical performance, the purpose of this study was to assess the relationship between residents' perceived stress and nontechnical skills during multidisciplinary trauma simulations.

METHODS

First-year surgery and emergency medicine residents voluntarily participated in this study. Residents participated in 3 trauma simulations across 2 training sessions in randomly assigned teams. Each team's nontechnical skills were evaluated by faculty using the Trauma Nontechnical Skills scale. The Trauma Nontechnical Skills scale consists of 5 items: leadership, cooperation, communication, assessment, and situation awareness/coping with stress. After each scenario, residents completed the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index to detail their perceived stress and workload during scenarios. Linear regressions were run to assess relationships between stress, workload, and nontechnical skills.

RESULTS

Twenty-five residents participated in the first simulation day, and 24 residents participated in the second simulation day. Results from regressions revealed that heightened stress and workload predicted significantly lower nontechnical skills performance during trauma scenarios. In regard to specific aspects of nontechnical skills, residents' heightened stress and workload predicted statistically significant lower situation awareness and decision-making during trauma scenarios.

CONCLUSION

Residents' perceived stress and workload significantly impaired their nontechnical skills during trauma simulations. This finding highlights the need to offer stress management and performance-optimizing mental skills training to trainees to lower their stress and optimize nontechnical skills performance during challenging situations.

Non-Technical Skill Assessment and Mental Load Evaluation in Robot-Assisted Minimally Invasive Surgery

BACKGROUND: Sensor technologies and data collection practices are changing and improving quality metrics across various domains. Surgical skill assessment in Robot-Assisted Minimally Invasive Surgery (RAMIS) is essential for training and quality assurance. The mental workload on the surgeon (such as time criticality, task complexity, distractions) and non-technical surgical skills (including situational awareness, decision making, stress resilience, communication, leadership) may directly influence the clinical outcome of the surgery. METHODS: A literature search in PubMed, Scopus and PsycNet databases was conducted for relevant scientific publications. The standard PRISMA method was followed to filter the search results, including non-technical skill assessment and mental/cognitive load and workload estimation in RAMIS. Publications related to traditional manual Minimally Invasive Surgery were excluded, and also the usability studies on the surgical tools were not assessed. RESULTS: 50 relevant publications were identified for non-technical skill assessment and mental load and workload estimation in the domain of RAMIS. The identified assessment techniques ranged from self-rating questionnaires and expert ratings to autonomous techniques, citing their most important benefits and disadvantages. CONCLUSIONS: Despite the systematic research, only a limited number of articles was found, indicating that non-technical skill and mental load assessment in RAMIS is not a well-studied area. Workload assessment and soft skill measurement do not constitute part of the regular clinical training and practice yet. Meanwhile, the importance of the research domain is clear based on the publicly available surgical error statistics. Questionnaires and expert-rating techniques are widely employed in traditional surgical skill assessment; nevertheless, recent technological development in sensors and Internet of Things-type devices show that skill assessment approaches in RAMIS can be much more profound employing automated solutions. Measurements and especially big data type analysis may introduce more objectivity and transparency to this critical domain as well. SIGNIFICANCE: Non-technical skill assessment and mental load evaluation in Robot-Assisted Minimally Invasive Surgery is not a well-studied area yet; while the importance of this domain from the clinical outcome's point of view is clearly indicated by the available surgical error statistics.

Value of Nontechnical Skills in Minimally Invasive Surgery

Nontechnical skills are of increasing importance in surgery and surgical training. The main studies on its impact on the safety and effectiveness of surgical interventions were mainly published in the first decade of the 2000s. Due to the significant technical complexity and great diversity of instruments for nontechnical skills evaluation, the interest in training and in measuring the impact on surgical safety has relatively decreased. However, the advent of minimally invasive surgery and its peculiar technical characteristics of sophisticated technique and constant innovation through the adoption of new materials and drugs has rekindled interest in this expertise area. In the present review, we have revisited the main instruments available to measure nontechnical skill of surgical teams and analyzed the role of the main competencies on which they are based, such as situational awareness, leadership and communication skills, and the consistency of the intraoperative decision-making process. We conclude that despite the great consensus that exists among all members of the health team on the importance of nontechnical skills for the surgical team in minimally invasive surgery, the reproducible evidence on the subject is scarce and laborious to obtain. To the extent that protecting and expanding nontechnical skills is fundamental to the path toward the high reliability of health institutions, it is possible to anticipate here the role of these institutions as promoters of continuity and new research models in this area of knowledge, especially in minimally invasive surgery, an access route to which more and more patients undergoing surgical treatment in these same institutions are submitted.

Analysis of Mirrored Psychophysiological Change of Cardiac Surgery Team Members During Open Surgery

OBJECTIVE

Mirrored psychophysiological change in cognitive workload indices may reflect shared mental models and effective healthcare team dynamics. In this exploratory analysis, we investigated the frequency of mirrored changes, defined as concurrent peaks in heart rate variability (HRV) across team members, during cardiac surgery.

DESIGN

Objective cognitive workload was evaluated via HRV collected from the primary surgical team during cardiac surgery cases (N = 15). Root mean square of the successive differences (RMSSD) was calculated as the primary HRV measure. Procedures were divided into consecutive nonoverlapping 5-minute segments, and RMSSD along with deviations from RMSSD were calculated for each segment. Segments with positive deflections represent above-average cognitive workload. Positive deflections and peaks across dyads within the same segment were counted.

SETTING

Data collection for this study took place in the cardiovascular operating room during live surgeries.

PARTICIPANTS

Physiological data were collected and analyzed from the attending surgeon, attending anesthesiologist, and primary perfusionist involved with the recorded cases.

RESULTS

Of the 641 five-minute segments analyzed, 325 (50.7%) were positive deflections above average, concurrently across at least 2 team members. Within the 325 positive deflections, 26 (8%) represented concurrent peaks in HRV across at least 2 active team members. Mirrored peaks across team members were observed most commonly during the coronary anastomoses or valve replacement phase (N = 12).

CONCLUSIONS

In this pilot study, mirrored physiological responses representing peaks in cognitive workload were observed uncommonly across dyads of cardiac surgery team members (1.73 peaks/case on average). Almost half of these occurred during the most technically demanding phases of cardiac surgery, which may underpin teamwork quality. Future work should investigate interactions between technical and nontechnical performance surrounding times of mirrored peaks and expand the sample size.

Teaching non-technical skills: the patient centered approach

The surgical setting is a highly complex environment where, in ideal conditions, everything should be under control to ensure a positive outcome. However, the existing complexity opens the possibility for multiple failures along the process and many of those failures are related to what is call the non-technical skills of the members of the team. We cannot eradicate human error, but we can try to avoid future mistakes in our daily practice introducing the awareness for providing a high-quality care in which patient safety is crucial. This paper presents an easy approach to concepts and teaching possibilities of those non-technical skills.

Nontechnical Skills (NTS) in the Undergraduate Surgical and Anesthesiology Curricula: Are We Adequately Preparing Medical Students?

OBJECTIVES

Nontechnical skills (NTS) encompass interpersonal, cognitive, and personal resource skills that can mitigate surgical errors and improve patient outcomes. However, inconsistencies in medical student awareness around NTS suggest limited exposure to these skills. This study aimed to determine the prevalence and content of NTS in medical school surgery and anesthesiology education.

DESIGN AND SETTING

Learning objectives from clerkship core surgery and anesthesiology rotations were collected from Canadian anglophone medical schools. Two raters independently classified each objective under one of the Non-Technical Skills for Surgeons (NOTSS) or Anaesthetists' Non-Technical Skills (ANTS) "Categories" and "Elements" of NTS, or as a non-NTS objective. Rater disagreements were resolved by group consensus. Group discussion was also held to identify examples of objectives that could help develop future curricula. Descriptive statistics were used to determine the number of NTS objectives from each school and within each NOTSS and ANTS Categories and Elements.

RESULTS

Learning objectives were obtained from 12 out of 14 Canadian medical schools. A total of 2116 surgery objectives and 571 anesthesiology objectives were reviewed. Of these, 16 (0.76%) and 26 (4.55%) were identified as NTS objectives in surgery and anesthesiology, respectively. Of the NOTSS and ANTS Categories, "Situation Awareness" and "Decision Making" were represented by only one objective each in both specialties. Approximately half of the NOTSS and ANTS Elements were not represented by a single objective. Group discussion yielded examples of NTS objectives that were excellent, could use improvement, or were too vague to be classified as NTS.

CONCLUSIONS

A paucity of objectives in the clerkship perioperative curricula involve NTS. These findings suggest that NTS are unlikely being adequately introduced as critical skillsets of surgeons and anesthesiologists in undergraduate perioperative education. Future curriculum development should involve greater medical student exposure to NTS as key components of their surgery and anesthesiology education.

Non-technical skills in oral and maxillofacial and head and neck surgery: systematic review

The importance of teams' and individuals' non-technical skills in reducing adverse events is well-recognised. We undertook a systematic review of the published literature to assess the research undertaken to date on non-technical skills and behaviours within oral and maxillofacial, and head and neck (OMFS-H&N) surgery. The aim was to assess the applicability of published studies to current practice, to look at how these studies could guide future research, and look for areas that could be developed further. The search terms included 'non technical skills', 'nontechnical skills', 'NOTSS', 'non-technical skills for surgeons', 'oral surgery', 'oral maxillofacial surgery', 'OMFS', 'maxillofacial surgery', 'head and neck surgery', 'microsurgery', 'behavioural markers', 'behavioural assessment tool', and 'behavioural ratings system'. Three publications were included, involving 83 participants. Participants consistently achieved the highest scores in the 'situational awareness' category and showed a tendency to achieve lower mean scores in the 'communication and teamwork' and 'decision-making' categories. The majority of research into surgeons' non-technical skills has occurred in simulated environments and not in the genuine environments in which actual surgery is being performed on patients. Research involving 'real' patients has been done in the field of OMFS-H&N and this places the specialty in a stronger position than many other surgical specialties.

Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BACKGROUND

Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings.

METHODS

We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

RESULTS

Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

CONCLUSION

Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

Have the Characteristics for Success as a Surgeon Changed? A Century of Perspective Through the American College of Surgeons

BACKGROUND

The Presidential Address of the American College of Surgeons (ACS) is an influential platform during the convocation for new Fellows every year. Recent work reported that most ACS presidents primarily discuss personal characteristics for success; however, these qualities were never specified. Therefore, this study aimed to identify the personal characteristics that are espoused in ACS presidential addresses as essential for success as a surgeon.

STUDY DESIGN

Thematic analysis was completed for every ACS presidential address (98 addresses between 1913 and 2019). Full-text addresses were reviewed (2 team members), personal characteristics were coded (1 team member) and then assembled into patterns and themes (3 team-members' consensus). A temporal frame was adopted in grouping these themes in that personal qualities that appeared consistently throughout this period were classified as Enduring Characteristics and those that emerged only in later years were classified as Recent Characteristics.

RESULTS

Enduring Characteristics that were present throughout the century included sincere compassion for patients; integrity; engagement (willingness to help shape the changing field at the institutional or national level); and commitment to lifelong learning. Recent Characteristics included humility and the interpersonal attributes of inclusivity and the ability to be a collaborative team leader.

CONCLUSIONS

Surgery has experienced countless paradigm shifts since 1913, and the perceived characteristics for success have similarly evolved to include more interpersonal abilities. The importance of sincere compassion for patients, integrity, engagement, and commitment to lifelong learning remained consistent for more than a century.

Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic

Background

The Severe Acute Respiratory Syndrome Coronavirus 2 pandemic has exposed surgeons to hazardous working conditions, imposing the need for personal protective equipment (PPE) use during surgery. The use of such equipment may affect their non-technical skills, augment fatigue, and affect performance. This study aimed to assess the surgeons’ perceptions of the impact of wearing PPE during emergency surgery throughout the pandemic.

Methods

An international cooperation group conducted an anonymous online survey among surgeons from over 30 countries, to assess perceptions about the impact of PPE use on non-technical skills, overall comfort, decision making, and surgical performance during emergency surgery on COVID-19 patients.

Results

Responses to the survey (134) were received from surgeons based on 26 countries. The vast majority (72%) were males. More than half of the respondents (54%) felt that their surgical performance was hampered with PPE. Visual impairment was reported by 63%, whereas 54% had communication impediments. Less than half (48%) felt protected with the use of PPE, and the same proportion perceived that the use of such equipment influenced their decision making. Decreased overall comfort was cited by 66%, and 82% experienced increased surgical fatigue.

Conclusions

Surgeons perceived impediment for both visibility and communication, and other non-technical skills while using PPE on emergency surgery in COVID-19 patients. Their perceived lack of protection and comfort and increased fatigue may have inhibited their optimal surgical performance. More attention should be placed in the design of more user-friendly equipment, given the possibility of a second wave of the pandemic.

Workplace based assessment: A review of available tools and their relevance

Workplace-based assessment (WPBA) appears to be a promising tool for more comprehensive assessment of the learners. Relevant literature in this direction was collated and analyzed for its relevance, salience, and merit. Many WPBA tools are being used by various educational institutions which spans across multiple domains and over the entire duration of the workplace learning. It caters to holistic assessment with structured measures, real-time feedback, and continuous professional development. It is being used more for formative assessment and has limited utility in summative assessment as on date. WPBA tools have promising prospect in bringing novelty, objectivity, and holistic approach in assessment.

Non-technical skills and otolaryngology: systematic review

OBJECTIVES

This study aimed to assess the published literature on non-technical skills in otolaryngology surgery and examine the applicability of any research to others' practice, and to explore how the published literature can identify areas for further development and guide future research.

METHODS

A systematic review was conducted using the following key words: 'otolaryngology', 'otorhinolaryngology', 'ENT', 'ENT surgery', 'ear, nose and throat surgery', 'head and neck surgery', 'thyroid surgery', 'parathyroid surgery', 'otology', 'rhinology', 'laryngology' 'skull base surgery', 'airway surgery', 'non-technical skills', 'non technical skills for surgeons', 'NOTSS', 'behavioural markers' and 'behavioural assessment tool'.

RESULTS

Three publications were included in the review - 1 randomised, controlled trial and 2 cohort studies - involving 78 participants. All were simulation-based studies involving training otolaryngology surgeons.

CONCLUSION

Little research has been undertaken on non-technical skills in otolaryngology. Training surgeons' non-technical skill levels are similar across every tested aspect. The research already performed can guide further studies, particularly amongst non-training otolaryngology surgeons and in both emergency and elective non-simulated environments.

Simulation-based acquisition of non-technical skills to improve patient safety

Traditional surgical training has focused on the acquisition of technical skills and knowledge with minimal focus on teaching nontechnical skills. Patient safety depends on both technical and nontechnical skills, with a higher rate of non-technical skills failure leading to patient harm. Many surgical training and regulatory bodies have incorporated nontechnical skills in the required competencies of a surgeon, but few have introduced formal training in nontechnical skills. Emerging research shows simulation-based education to be a powerful tool to teach nontechnical skills to individual surgeons and surgeons in training, and to interprofessional surgical teams with subsequent improvement of patient safety outcomes.

Identification of the Critical Nontechnical Skills for Surgeons Needed for High Performance in a Variable-resource Context (NOTSS-VRC)

OBJECTIVE

To identify the critical nontechnical skills (NTS) required for high performance in variable-resource contexts (VRC).

BACKGROUND

As surgical training and capacity increase in low- and middle-income countries (LMICs), new strategies for improving surgical education and care in these settings are required. NTS are critical for high performance in surgery around the world. However, the essential NTS used by surgeons operating in LMICs to overcome the challenges specific to their contexts have never been described.

METHOD

Using a constructivist grounded theory approach, 52 intraoperative team observations as well as 34 critical incident interviews with surgical providers (surgeons, anesthetists, and nurses) were performed at the 4 tertiary referral hospitals in Rwanda. Interview transcripts and field notes from observations were analyzed using line-by-line coding to identify emerging themes until thematic saturation was achieved.

RESULTS

Four skill categories of situation awareness, decision-making, communication/teamwork, and leadership emerged. This provided the framework for a contextually informed skills taxonomy consisting of 12 skill elements with examples of specific behaviors indicative of high performance. While the main skill categories were consistent with those encountered in high-income countries, the specific behaviors associated with these skills often focused on overcoming the frequently encountered variability in resources, staff, systems support, and language in this context.

CONCLUSION

This is the first description of the critical nontechnical skills, and associated example behaviors, used by surgeons in a VRC to overcome common challenges to safe and effective surgical patient care. Improvements in the NTS used by surgeons operating in VRCs have the potential to improve surgical care delivery worldwide.

In Search of Characterizing Surgical Skill

OBJECTIVE

This paper provides a literature review and detailed discussion of surgical skill terminology. Culminating in a novel model that proposes a set of unique definitions, this review is designed to facilitate shared understanding to study and develop metrics quantifying surgical skill.

DESIGN

Objective surgical skill analysis depends on consistent definitions and shared understanding of terms like performance, expertise, experience, aptitude, ability, competency, and proficiency.

STRUCTURE

Each term is discussed in turn, drawing from existing literature and colloquial uses.

IMPLICATIONS

A new model of definitions is proposed to cement a common and consistent lexicon for future skills analysis, and to quantitatively describe a surgeon's performance throughout their career.