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but trainer time is limited, so the performance prescription format
requires relevant details, no more, no less. No lengthy outlines are
needed, just precise, specific descriptions. The format allows for a
balanced assessment and feedback on what the trainee has done well
alongside identification of where performance can be improved."
So what are the key problems with OPRs? Not all cases are captured,
Dr Sanfey reports, and there can be instances where evaluations are
not made in the immediate aftermath of operative performance.
Most significantly, she cites research that indicates 72 per cent of
consultant OPRs lacked comments. "There are several contributory
factors, including the major challenge of time constraints, as well as
concern over retaliation and lawsuits. But there are steps that can
be taken to mitigate these problems, including the establishment of
teaching awards to encourage a rise in the quality of the evaluation
process. It's also helpful if pass/fail or promotion decisions are not
required to be made by trainers."
Dr Sanfey emphasises the importance of a well-documented,
promptly recorded evaluation process. "The evaluation process not
only must be fair, it must be seen to be fair and evidence-based.
A regular, precise record will ensure that a trainee has notice of
a deficiency where it exists, has the opportunity to remedy the
deficiency and improve within a clearly defined timeline, and is
aware of the consequences of failure or success. This is all about
following through as promised. It is also about clarifying what would
otherwise be elusive and difficult-to-measure answers to questions
such as:
can the trainee's behaviour be improved to an effective
performance level?
is the trainee's performance having a hidden cost in terms of
increased workload on colleagues and low morale?
how much time is spent discussing the individual? and,
most importantly, what is the impact on patient care?
In conclusion, Dr Sanfey lists some overall guidelines: "Technical
skills should be a focus of assessment of juniors while non-
technical skills should be the focus in training seniors. Operative
evaluation should be applied in cases in which residents do most of
the planning and team direction. Guidance should be adjusted in
alignment with trainee seniority.
"In working out an optimum level of evaluation, it's suggested
that there should be 20 evaluations per year per trainee. Ideally,
there should be 10 different assessors per year per trainee. And
evaluations should be completed within a maximum of three days of
Dr Sanfey's comments in the main article are based on findings from
the following research papers:
Ahlberg G et al. Am J Surg. 2007; 193 (6): 797
Chen P et al. Am J Surg. 2012; 203: 44-48
Grantcharov T et al. ANZ J Surg 2009; 79: 104
Kim M et al. J Surg Ed. 2009; 66: 352 [check]
Larson J et al. SURGERY. 2005; 138: 640
Moulton CA et al. Acad Med. 2007; 82 (Suppl):S109
Roberts N et al. JGME. 2011
Sanfey H et al. SURGERY. 2011; 150:759
Sanfey et al. JACS 2012; 216 (1): 114
Stefanidis D et al. Surgical Innovation. 2008; 15 (1): 69
Williams RG et al. Annals of Surgery. 2012; 256 (1):177
In looking at the new pathway, Dr Sanfey says
that, overall, it represents a positive and necessary
transformation in the training programme: "When I
trained, it took fourteen years in total. The eight-year
duration of the new pathway is a major benefit for
trainees and takes account of the changing realities
of modern, 21st Century healthcare while focusing on
graduating surgeons with a high level of proficiency
and, thereby, delivering optimum patient safety.
At the same time, she notes: "It must be recognised
that the pathway assessment process makes specific
demands on trainers to ensure that it is comprehensive
and fair. In particular, every effort must be made to
ensure the process achieves a systematic, ongoing
documentation of trainee performance. It is productive
to look at any measures that can be taken to make
the documentation process more efficient. The
development of a documentation app for smartphones,
tablets etc could be particularly useful.
"Overall, the assessment process must be as
transparent as it is effective in assessing proficiency, so
that all stakeholders are satisfied that outcomes and
decisions are not capricious."
Dr Hilary Sanfey specialises in kidney/pancreas transplantation. She received both her undergraduate and medical
training from Trinity College Dublin, undergoing her surgical training in RCSI and Guys Hospital in London. Dr Sanfey
completed a fellowship in solid organ transplantation at the University of Virginia in 1997.
Prior to joining SIU, Dr Sanfey was Professor of Surgery with the University of Virginia Health System.
In addition to being on the Board of Governors of the American College of Surgeons, Dr Sanfey is a member of several
medical societies, including the Association of Women Surgeons, the American Association of Transplant Surgeons and
the Association for Surgical Education.
Her research interests include resident learning styles, the impact of resident teachers on medical student learning and
leadership development.
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