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Current Protocols Insufficiently Assess Surgical Skills

In a paper published in Archives of Otolaryngology-Head & Neck Surgery entitled “Criterion-Based (Proficiency) Training to Improve Surgical Performance,” researchers at Montefiore Medical Center have demonstrated that current requirements for surgical proficiency, including the performance of a fixed number of surgeries, insufficiently assesses surgical capabilities and does not take into consideration individual learning differences. The paper also reveals that simulation training can vastly improve trainee surgeons’ skills prior to operating on live patients.

Marvin P. Fried, MD, FACS, University Chairman Department of Otorhinolaryngology-Head and Neck Surgery at Montefiore Medical Center, was the Principle Investigator of this study, which took place over a five year period and is the last in a series of studies carried out by Dr. Fried and his team. “We have been studying this subject since 2000 and the results of each of our studies have shown that technical abilities are highly individualistic, skill levels progress at varying speeds. Simulation training is an invaluable tool in creating a competent surgeon in a safe and controlled environment, which ultimately helps to ensure patient safety and produce the best outcomes,” said Dr. Fried.

In the paper published last week, 20 subjects from Montefiore Medical Center and New York University Medical Center were divided into three groups. 14 Otorhinolaryngology junior residents in post-graduate year 1 – 3, were designated to either the experimental group which had eight subjects, or the control group which had six subjects. There was also a third group of six attending surgeons who set the benchmark against which the other groups were compared.

All three groups performed Endoscopic Sinus Surgery, a procedure undergone by over 500,000 people per year, which involves removing blockages in the sinuses, allowing increased air flow through and enabling the nose to drain properly. During this surgery, an endoscope is inserted through the nostrils, allowing the doctor to identify the blocked areas and remove the blockages with surgical instruments. Associated risks can be damage to the eye or injury to the brain. The experimental group was trained to proficiency on the simulator and the control group was trained in the current standard fashion by performing a limited number of defined sinus surgery procedures. Both groups were then compared to each other and with the attending surgeons who were experts in this type of procedure.

This is in contrast to current surgical training which typically lasts for a specified time period or number of procedures, thereby producing surgeons with variable skill levels – a practice that is becoming less acceptable for patient safety.

Subjects in both resident groups had performed fewer than five cases as the primary surgeon at the start of the trial and were video-recorded as they performed one procedure on a live patient.  All were determined to have had the same initial performance.  The experimental group then performed the surgery on a state-of-the-art device, the Endoscopic Sinus Surgery Simulator (ES3). The ES3 ensures skill proficiency by training to expert criteria, testing and training users at various levels, only allowing the user to progress to the next level once a certain skill level has been achieved. The experimental group trained by performing trials at the intermediate level of the simulator.

The control group assisted in two additional endoscopic sinus surgery cases, consistent with standard training process. All resident subjects were then video-recorded while performing the same surgical procedure on a patient and a panel of experts, senior academic Otorhinolaryngologists with expertise in endoscopic sinus surgery, compared the videos to assess skill levels. The panel judged the anonymous videos on several criteria including: time to completion of task, case difficulty, tool manipulation, tissue respect, task completion rate, surgical confidence and number of errors, and provided an overall score at the end of the video. All subjects were de-identified in the video-recordings and all procedures had a similar level of case difficulty.

Results show that both the experimental and control groups’ final procedures were superior compared to initial procedures, however, the experimental group, who were trained on the surgical simulator, at minimum performed similarly if not outperformed control subjects in the final procedure and were indistinguishable in some tasks from the attending surgeons. Further supporting the theory that proficiency is achieved at varying speeds, the experimental group could be divided into two subgroups: five subjects achieved proficiency levels on the intermediate mode of the simulator in less than six trials and the remaining three subjects achieved such proficiency in more than twelve trials, highlighting the necessity of technical skill assessment of surgical residents rather than the traditional method of performing a specified number of procedures.

“The acquisition of surgical skills currently requires live patient experience with finite availability; this produces a wide range of abilities within the resident population. As not all trainees develop skill sets equivalently, criterion-based training can enable the resident to bypass the initial learning curve, and potentially protect patients from novice errors during this period. Surgical simulators can fill the need for training outside of the operating room, reduce the variability in skill level and improve operating room safety and efficiency,” commented Dr. Fried.

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