he starting point in the structuring of any surgical
training programme must be the prioritisation
of patient safety, Dr Sanfey states. "Patient safety
is the guiding principle that shapes the design
and framework of a training programme. With
that defining objective, we can address key
questions. How can we optimally prepare surgical trainees for
safe, independent practice? How can we most accurately and
comprehensively document their proficiency? What steps can be
taken if trainees are not proficient? And what appropriate and
relevant support can be given to trainers?"
Measuring proficiency is a complex process, she notes: "In
proficiency-based training, key challenges are to ensure trainees
perform to a uniform level and that there is a common standard of
measurement in the Operative Performance Rating (OPR). These
challenges are exacerbated by the difficulty of establishing uniformity
in evaluation standards generally and the absence of a clear
classification of deficiencies in operative performance."
Dr Sanfey points out that, for instance, there is a lack of awareness
of cueing or guidance by most teaching surgeons. "Cueing can take
various forms. It can be verbal or it can involve pointing with forceps
or lap sponges or, less directly, the camera view can be used to frame
procedural steps. This means that non-technical deficiencies may not
be apparent until late in training when trainees operate with a greater
degree of autonomy."
There are key trainee criteria that trainers must assess: technical skills;
forward planning; self-direction; judgement and safety; and situation
awareness. "Technical skills are, essentially, the ability to use surgical
instruments effectively and efficiently and include mastering economy
of motion and bimanual manipulation, for example.
"Moving on from technical skills, forward planning entails being
able to anticipate needs, think ahead and set up the operative field.
How does the trainee translate learned knowledge to the reality of
what he or she sees during dissection? Self-direction is about factors
such as trainee demeanour and the ability to focus and ignore
distraction, as well as the trainee's ease with accepting feedback. Is
dissection handled with patience and care? Is there a willingness to
"Judgement and safety cover the capacity to problem solve, to
identify and avoid errors and, where necessary, to recover from
errors or unexpected occurrences. The range of issues raised under
this criterion include how methodical and safe the trainee's work is;
whether anatomy is identified accurately and safely; and, if an error
is made, what is its exact detail."
When measuring situation awareness, Dr Sanfey says trainers need
to document situation assessment ability, the trainee's interpretation
of cues from the environment and the capacity for team leadership.
"How does the trainee guide the team? Does he or she demonstrate
patience and instructional skills?"
Across the range of non-technical skills, the trainee must be
allowed autonomy, if a full and accurate evaluation of such skills is
to be made. "Only if the trainee is allowed to assume control can a
comprehensive assessment be made of the trainee's ability to answer
`what if' questions. Similarly, whether or not the trainee is slowing
down appropriately is evident only when he or she is independently
determining the pace of performance. Trainee autonomy is
necessary for the trainer to assess the trainee's awareness of changes
in patient status, equipment availability, the potential for error,
anatomical variations and so on. The trainer can only decide
on appropriate remediation be it reading, mental rehearsal,
simulation or other techniques when a correct assessment of non-
technical skills is made," Dr Sanfey says.
At Southern Illinois University, some trainers use a postcard-size
`prescription' to provide trainee feedback. "Documentation is vital
IN SURGICAL TRAINING
DR HILARY SANFEY, PROFESSOR OF
SURGERY AND VICE CHAIR FOR EDUCATION,
DEPARTMENT OF SURGERY, SOUTHERN ILLINOIS
UNIVERSITY SCHOOL OF MEDICINE, ILLINOIS,
US, IS COMPLETING A THREE MONTH VISIT TO
RCSI TO OBSERVE THE ASSESSMENT PROCESS
IN THE COLLEGE'S NEW TRAINING PATHWAY. DR
SANFEY SPOKE TO SURGICAL SCOPE ABOUT KEY
ISSUES IN SURGICAL TRAINING