Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
Ann Surg. 2018 Aug;268(2):385-390. doi: 10.1097/SLA.0000000000002284.
The present study asks whether intraoperative principles are shared among faculty in a single residency program and explores how surgeons' individual thresholds between principles and preferences might influence assessment.
Surgical education continues to face significant challenges in the implementation of intraoperative assessment. Competency-based medical education assumes the possibility of a shared standard of competence, but intersurgeon variation is prevalent and, at times, valued in surgical education. Such procedural variation may pose problems for assessment.
An entire surgical division (n = 11) was recruited to participate in video-guided interviews. Each surgeon assessed intraoperative performance in 8 video clips from a single laparoscopic radical left nephrectomy performed by a senior learner (>PGY5). Interviews were audio recorded, transcribed, and analyzed using the constant comparative method of grounded theory.
Surgeons' responses revealed 5 shared generic principles: choosing the right plane, knowing what comes next, recognizing normal and abnormal, making safe progress, and handling tools and tissues appropriately. The surgeons, however, disagreed both on whether a particular performance upheld a principle and on how the performance could improve. This variation subsequently shaped their reported assessment of the learner's performance.
The findings of the present study provide the first empirical evidence to suggest that surgeons' attitudes toward their own procedural variations may be an important influence on the subjectivity of intraoperative assessment in surgical education. Assessment based on intraoperative entrustment may harness such subjectivity for the purpose of implementing competency-based surgical education.
本研究旨在探讨单一住院医师项目中的教员是否共享术中原则，并探讨外科医生个人在原则和偏好之间的阈值如何影响评估。
手术教育在实施术中评估方面仍然面临重大挑战。基于能力的医学教育假设存在共同能力标准的可能性，但外科医生之间的差异普遍存在，有时在手术教育中受到重视。这种程序上的差异可能会给评估带来问题。
招募了整个外科部门（n=11）参与视频引导的访谈。每位外科医生评估了 8 个视频剪辑中的术中表现，这些视频剪辑来自一位高级学习者（>PGY5）进行的单次腹腔镜根治性左肾切除术。使用扎根理论的恒定性比较方法对访谈进行录音、转录和分析。
外科医生的回答揭示了 5 个共同的通用原则：选择正确的平面、了解下一步、识别正常和异常、安全进展以及妥善处理工具和组织。然而，外科医生不仅对特定表现是否符合原则存在分歧，而且对如何改进表现也存在分歧。这种差异随后影响了他们对学习者表现的评估报告。
本研究的结果首次提供了经验证据，表明外科医生对自己程序差异的态度可能对手术教育中术中评估的主观性产生重要影响。基于术中委托的评估可以利用这种主观性来实施基于能力的外科教育。
