Intraoperative Assessment of Residents (2013)

The safe performance of procedures is among the most critical aspects confronting surgical resident education. Increasing public concerns about physician performance and patient safety have augmented the need to demonstrate competence in surgical skills.1 Assessment of residents' operative skills should be both formative (feedback to the resident outlining areas for performance improvement) and summative (a statement of the resident's competence and skill level). With progressive experience and competence, advanced responsibility can be assigned to residents in complex operations.Intraoperative assessment of residents can be particularly challenging. Surgical skills are attained through practice and include a combination of motor skills, judgment, and medical knowledge. Furthermore, most surgical specialties do not have well-defined criteria for surgical competence; the bar for a minimal performance standard has not yet been set. A major goal of the Accreditation Council for Graduate Medical Education (ACGME) milestones is to define which skills should be attained with each year in training. Although operative skills are not explicitly included as 1 of the 6 general competencies, operative assessment will include aspects of all 6 competencies.Operative assessment can be formative to provide feedback for making the procedure a better educational experience or summative to assess a resident's competence for a particular procedure or skill.2–6 Written assessment of operative skills has been studied in a variety of surgical fields, including general medicine,7 orthopedic practice,46 otolaryngology,8 neurological surgery, and obstetrics and gynecology.9 More effective assessment derives from multiple assessments over time by multiple faculty members. Assessment tools can be general or procedure specific. More consistent feedback will be provided with a structured instrument developed for a specific procedure, such as carpal tunnel release.6 The development of valid and reliable assessment tools is an area of active study by various surgical specialties.15810Feedback (oral and written) about procedural performance is best provided to the resident as soon as possible after the procedure is done. The evaluating faculty member and resident will have a better recall of intraoperative events the same day than they will a week later.10 Use of a written assessment tool encourages the faculty and the resident to focus on areas of demonstrated competence and those areas needing improvement.A written intraoperative assessment provides a structured format for feedback to the resident. Even with imperfect assessment tools, feedback can be effective. A commonly used technique is to use a preoperative plan, written by the resident before the operative procedure, as a feedback template. Elements of a preoperative plan include the sequential steps of the procedure, a drawing of the anatomy involved with the procedure, and a list of specific equipment needed for the procedure.410The preoperative plan can be used as a structured document to review the planned operative procedure with the resident beforehand. This discussion will ensure that the resident understands the procedure and has the opportunity to ask any last-minute questions. In addition, the preoperative plan can be discussed with nursing staff and be used as a checklist for making sure equipment is available and the operating room is ready to care for the patient.410Intraoperative assessment is performed with an instrument, such as the sample Objective Assessment of Technical Skills tool shown in the box. It may be used alone with a designated procedure or to complement the preoperative plan. Intraoperative assessments usually assess a resident's technical skills for a designated procedure.