Forensic assessment of somatoform and functional neurological disorders.

Functional neurological disorders (FND) and somatization are common in clinical practice and medicolegal settings. These conditions are frequently disabling and, if arising following an accident, may lead to claims for legal compensation or occupational disability (such as social security disability insurance). However, distinguishing FND and somatization from symptoms that are intentionally produced (i.e., malingered or factitious) may pose a major forensic psychiatric challenge. In this article, we describe how somatoform disorders and FND lie along a spectrum of abnormal illness-related behaviors, including factitious disorder, compensation neurosis, and malingering. We provide a systematic approach to the forensic assessment of FND and conclude by describing common litigation scenarios in which FND may be at issue. Forensic testimony may play an important role in the resolution of such cases.

The surgical efficiency score: a feasible, reliable, and valid method of skills assessment.

BACKGROUND: Technical skills assessments are being increasingly used in surgical residency programs, with the objectivity and validity of several techniques well established. However, many of these methods are labor and time intensive, limiting their feasibility. This study aims to compare more efficient techniques of skills appraisals with an established gold standard. METHODS: Thirty surgeons completed 2 previously validated laboratory-based surgical models: small bowel anastomosis and vein patch insertion. Gold standard evaluation was the Objective Structured Assessment of Technical Skills (OSATS) method. "Efficient" techniques used were (1) quality of final product (FP); (2) snapshot assessment (SS), in which task performance was edited to a 2-minute sound bite and scored with OSATS; and (3) the surgical efficiency score (SES), a combination of final product quality and hand-motion analysis. All human observer evaluations used retrospective video analysis with 3 trained observers. Nonparametric tests were used to analyze the results. RESULTS: With respect to small bowel anastomosis, correlations with OSATS were as follows: FP 0.341 (P=.07), SS 0.577 (P<.001), and SES 0.842 (P<.001). For vein patch insertion, the correlations were as follows: FP 0.545 (P=.001), SS 0.609 (P<.001), and SES 0.700 (P<.001). Interobserver concordance was high for both models with respect to FP (Cronbach's alpha 0.80 for small bowel anastomosis and 0.84 for vein patch insertion). With respect to SS, interobserver reliability was high for vein patch insertion (Cronbach's alpha 0.80) but only moderate for small bowel anastomosis (0.59). CONCLUSIONS: The surgical efficiency score and snap shot assessments both show significant correlations with the traditional OSATS appraisals and suggest that skills assessment can be made more feasible. Correlations were closer with the former and interobserver concordance more variable with the latter, suggesting the surgical efficiency score as the most reliable of the methods evaluated.

Multiple Objective Measures of Skill (MOMS): a new approach to the assessment of technical ability in surgical trainees.

OBJECTIVE: The assessment of surgical technical skills has become an important topic in recent years. This study presents the validation of a 6-task skills examination for junior surgical trainees (at the level of the Membership of the Royal College of Surgeons). SUMMARY BACKGROUND DATA: Six tasks were evaluated in a project that also examined the feasibility of this method of assessment. The tasks were knowledge of sutures and instruments; knowledge of surgical devices; knot formation; skin-pad suturing, closure of an enterotomy; excision of a skin lesion; and laparoscopic manipulation. Comparisons were made between a group of junior trainees (n = 13), and a group of seniors (n = 8). RESULTS: Each of the 6 tasks was able to be used to discriminate between the 2 groups. In all, there were 19 primary analyses across the 6 tasks, and 17 of these showed significant differences between the groups (P values ranging from 0.037 to < 0.001). There was generally a strong correlation between the analyses, and when a mean rank was calculated, the difference between groups was significant (P = 0.005 on Mann-Whitney U test; mean ranks 13.9 and 6.3 [of 21], for juniors and seniors respectively). Reliability of the 6-task assessment was very good at 0.70 (Cronbach's Alpha). CONCLUSIONS: A skills examination is a feasible and effective method of assessing the technical ability of basic surgical trainees.

The surgical error examination is a novel method for objective technical knowledge assessment.

BACKGROUND: Objective analysis of surgical skill is necessary. A novel method of assessment using simple error analysis in synthetic models is examined for construct validity. METHODS: Two examination protocols were devised using synthetic models. These contained either a purpose made error or were representative of good surgical practice. Protocol one contained models of skin closure and minor operations. Protocol two in addition more complex procedures. Face validity was established by the approval of senior surgeons. Junior surgeons were recruited to undertake the assessment. A p value of less than 0.05 was deemed to be significant. RESULTS: Eighty-nine surgeons were recruited. Both protocol one and two were able to discriminate between groups at statistically significant levels. CONCLUSIONS: Construct validity has been established by showing that error analysis is able to distinguish surgeons with varying levels of experience.

Electromagnetic motion analysis in the assessment of surgical skill: Relationship between time and movement.

INTRODUCTION: Electromagnetic motion analysis is a promising method of assessing surgical skill in a skills-laboratory setting. There is a very strong correlation between movement and time data, and this study was conducted to determine whether this relationship is fixed, or whether it can vary. METHODS: : After a pilot study, four subjects were recruited. Each performed 30 trials of a simple standardized suturing task, alternating between 'normal', 'precise', and 'fast' strategies. The number of movements, and time to complete each task were recorded. RESULTS: Comparing the 'fast' to 'normal' strategies, there was a significant decrease in total number of movements per trial (P < 0.001), and time taken (P < 0.001). Regression analysis was performed to examine the relationship between the time taken and the number of movements, and revealed significant differences between both the fast (P = 0.006), and precise (P = 0.002) strategies, when compared to the normal strategy. DISCUSSION: This study confirms that the relationship between time and movements is not fixed, but varies with the operative strategy adopted for this simple suturing task.