Human Factors Approach to Assess Physician Workload in Elective Plastic Surgery Breast Procedures.

Background: Human factors research involves the study of work system interactions, physician workload, cognitive effort, and performance. This pilot study incorporated a human factor approach and other surgery-based metrics to assess cognitive workload among plastic surgeons during elective plastic surgery breast procedures. Methods: In this prospective study of plastic surgery breast procedures over a 3-month period, surgeon and patient demographics and procedural details were collected. The lead surgeon assessed each procedure using a validated workload questionnaire (National Aeronautics and Space Administration Task Load Index [NASA-TLX]) that included 6 subscales (ie, mental, physical, temporal demand, performance, effort, and frustration), a question on distraction, and their expectation of procedural difficulty. Results: Fifty-seven cases were included in this study. Surgical duration had a positive correlation with increased mental demand (P < .001), physical demand (P < .001), and degree of distractions (P < .001). Free flap reconstruction, breast reduction, and transgender mastectomy had the highest average mental, physical demands, and perceived effort. Bilateral cases had significantly higher workload than unilateral ones (P = .002). NASA-TLX scores between immediate and delayed reconstructions were comparable, but delayed cases had higher degree of distractions (P = .04). There was a strong correlation between degree of distractions and increased mental workload (R = 0.68; P < .001), increased physical demand (P = 0.61; P < .001), and increased temporal demand (R = 0.78; P < .001). More difficult procedures were associated with greater procedural duration than those rated as difficult as expected or less difficult than expected (P = .02). Conclusions: These preliminary data demonstrated multiple factors that may influence and govern perceived physician workload and may provide insight for targeted quality improvement to plan procedures safely and effectively.

Intraoperative Ergonomic Assessment of Exoscopes versus Conventional DIEP Flap.

BACKGROUND: This study compared the ergonomics of surgeons during deep inferior epigastric perforator (DIEP) flap surgery using either baseline equipment (loupes, headlights, and an operating microscope) or an exoscope. Plastic surgeons may be at high risk of musculoskeletal problems. Recent studies indicate that adopting an exoscope may significantly improve surgeon postures and ergonomics. METHODS: Postural exposures, using inertial measurement units at the neck, torso, and shoulders, were calculated in addition to the surgeons' subjective physical and cognitive workload. An ergonomic risk score on a scale of 1 (lowest) to 4 (highest) was calculated for each of the postures observed. Data from 23 bilateral DIEP flap surgeries (10 baseline and 13 exoscope) were collected. RESULTS: The neck and torso risk scores decreased significantly during abdominal flap harvest and chest dissection, while right shoulder risk scores increased during the abdominal flap harvest for exoscope DIEP flap procedures compared with. Exoscope anastomoses demonstrated higher neck, right shoulder, and left shoulder risk scores. The results from the survey for the "surgeon at abdomen" showed that the usage of exoscopes was associated with decreased performance and increased mental demand, temporal demand, and effort. However, the results from the "surgeon at chest" showed that the usage of exoscopes was associated with lower physical demand and fatigue, potentially due to differences in surgeon preference. CONCLUSION: Our study revealed some objective evidence for the ergonomic benefits of exoscope; however, this is dependent on the tasks the surgeon is performing. Additionally, personal preferences may be an important factor to be considered in the ergonomic evaluation of the exoscope.

Intraoperative workload during robotic radical prostatectomy: Comparison between multi-port da Vinci Xi and single port da Vinci SP robots.

The goal of this study was to quantify and compare prospective self-reported intraoperative workload and teamwork during robot-assisted radical prostatectomy (RARP) for multi-port da Vinci Xi (MP) and single-port da Vinci SP (SP) robots. The self-reported workload (surgeon and surgical team) and teamwork (surgeon) measures were collected and compared between MP and SP RARPs, as well as the learning curve. Results from 25 MP and SP RARPs showed that overall, the NASA-TLX workload subscales were lower, and the teamwork modified NOTECHS subscales were higher for the MP RARPs compared to the SP RARPs. The underlying reason for the significant differences between these two RARP surgical procedures could be other factors (e.g., robot design factors) in addition to the surgeon and surgical team's experience. The results also suggested learning effects through the 25 SP RARPs; however, twenty-five procedures may not be enough to achieve proficiency with the SP system.

Workload Differentiates Breast Surgical Procedures: NSM Associated with Higher Workload Demand than SSM.

BACKGROUND: Breast surgery has evolved with more focus on improving cosmetic outcomes, which requires increased operative time and technical complexity. Implications of these technical advances in surgery for the surgeon are unclear, but they may increase intraoperative demands, both mentally and physically. We prospectively evaluated mental and physical demand across breast surgery procedures, and compared surgeon ergonomic risk between nipple-sparing (NSM) and skin-sparing mastectomy (SSM) using subjective and objective measures. METHODS: From May 2017 to July 2017, breast surgeons completed modified NASA-Task Load Index (TLX) workload surveys after cases. From January 2018 to July 2018, surgeons completed workload surveys and wore inertial measurement units to evaluate their postures during NSM and SSM cases. Mean angles of surgical postures, ergonomic risk, survey items, and patient factors were analyzed. RESULTS: Procedural duration was moderately related to surgeon frustration, mental and physical demand, and fatigue (p < 0.001). NSMs were rated 23% more physically demanding (M = 13.3, SD = 4.3) and demanded 28% more effort (M = 14.4, SD = 4.6) than SSMs (M = 10.8, SD = 4.7; M = 11.8, SD = 5.0). Incision type was a contributing factor in workload and procedural difficulty. Left arm mean angle was significantly greater for NSM (M = 30.1 degrees, SD = 6.6) than SSMs (M = 18.2 degrees, SD = 4.3). A higher musculoskeletal disorder risk score for the trunk was significantly associated with higher surgeon physical workload (p = 0.02). CONCLUSION: Nipple-sparing mastectomy required the highest surgeon-reported workload of all breast procedures, including physical demand and effort. Objective measures identified the surgeons' left upper arm as being at the greatest risk for a work-related musculoskeletal disorder, specifically from performing NSMs.

Surgeon Workload in Colorectal Surgery: Perceived Drivers of Procedural Difficulty.

BACKGROUND: To understand how surgeon expectation of case difficulty relates to workload for colon and rectal procedures and to identify possible surgeon-perceived drivers contributing to case difficulty. MATERIALS AND METHODS: For 3 mo, surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) questionnaire following each surgical case. Questions included items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 = low, 20 = high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Surgeons also reported perceived drivers contributing to case ease or difficulty. Patient and procedural data were analyzed for procedures with completed surveys. RESULTS: Seven surgeons (three female) rated 122 procedures over the research period using a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort (mean [M] = 10.83, standard deviation [SD] = 5.66) followed by mental demand (M = 10.18, SD = 5.17), and physical demand (M = 9.19, SD = 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases. CONCLUSIONS: Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus.

NASA-Task Load Index Differentiates Surgical Approach: Opportunities for Improvement in Colon and Rectal Surgery.

OBJECTIVE: Surgeon workload, or human "cost" of performing a procedure, is not well understood in light of emerging surgical technologies. This pilot study quantified surgeon workload for colorectal procedures and identified patient, surgeon, and procedural factors impacting workload. SUMMARY BACKGROUND DATA: Innovative technologies and procedures in surgery have generally been promoted for the advancement of patient care. The resulting surgeon workload is poorly studied with little knowledge of the contributing factors impacting workload. METHODS: Surgeons completed NASA-Task Load Index (NASA-TLX) questionnaires to self-assess workload following abdominopelvic colon and rectal procedures. Corresponding patient data were retrieved from the medical record. Descriptive statistics, correlations, and ANOVA were performed to compare surgeon and patient factors, procedure type, and surgical approach on workload overall and by subscales. RESULTS: Seven attending surgeons rated 238 surgeries, of which 218 (92%) had corresponding patient data. Surgeon experience and patient demographics had inconsistent effects on workload. A statistically significant 3-way interaction was identified among disease process, procedure type, and surgical approach on workload (F(9, 146) = 2.17, P = 0.027), but was limited to open procedures for neoplasia and inflammatory bowel disease patients. Proctectomy and colectomy procedures compared across open, laparoscopic, and robotic approaches showed significant differences in overall workload and subscales, where the robotic procedures required significantly less mental demand, physical demand, and effort, than open or laparoscopic (P < 0.05). CONCLUSIONS: Patient characteristics, disease process, and surgical experience had inconsistent effects on surgeon workload. Major differences in workload were identified for procedure type and surgical approach, where robotic procedures required less mental demand, physical demand, and effort.

Use of error management theory to quantify and characterize residents' error recovery strategies.

BACKGROUND: Traditional checklist metrics for surgical performance can miss key intraoperative decisions that impact procedural outcomes. Error-based assessments may help identify important metrics for evaluating operative performance and resident readiness for independent practice. METHODS: This study utilized human factors error analysis and error management theory to investigate a previously collected video database of resident performance during a simulated laparoscopic ventral hernia (LVH) repair on a table-top simulator using standard laparoscopic tools and mesh. Errors were deconstructed and coded using a structured observation tool and video analysis software. Error detection events and error recovery events were categorized for each operative step of the ventral hernia repair. RESULTS: Residents made a total of 314 errors (M = 15.7, SD = 4.96). There were more technical errors (63%) than cognitive errors (37%) and more commission errors (69%) than omission errors (30%). Almost half (47%) of all errors went completely undetected by the residents for the entire LVH repair. Of the errors that residents attempted to recover (n = 136), 86.0% were successfully recovered. Technical errors were four times more likely to be successfully recovered than cognitive errors (p = .020). CONCLUSIONS: Our results revealed specific details regarding residents' error management strategies and provides validity evidence for the use of human factors error frameworks in surgical performance assessments. Practice in simulation-based learning environments may improve resident decision-making and error management opportunities by providing a structured experience where errors are explicitly characterized and used for training and feedback. Error management training may play a major role in equipping residents and junior faculty with the skills required for independent, high-quality operative performance.

A pilot study of non-routine events in gynecological surgery: Type, impact, and effect.

OBJECTIVE: Quantifying non-routine events (NREs) assists with identify underlying sociotechnical factors that could lead to adverse events. NREs are considered any event that is unusual or atypical during surgical procedures. This study aimed to use prospective observations to characterize the occurrence of non-routine events in gynecological surgeries. METHODS: Observational data were collected prospectively within one surgical gynecology department over a five month period. Researchers captured NREs in real time using a validated tablet PC-based tool according to the NRE type, impact, whom was affected, and duration. Researchers also noted what surgical approach (i.e. open, laparoscopic, robotic) was used. RESULTS: Across 45 surgical cases, 554 non-routine events (M = 12.31 NREs per case, SD = 9.81) were identified. The majority of non-routine events were external interruptions (40.3%), teamwork (26.7%), or equipment (21.3%). The circulating nurse was most frequently affected by NREs (43.2%) followed by the entire surgical team (13.7%). There was no statistically significant difference in non-routine events based on surgical approach. CONCLUSION: Non-routine events are prevalent in the gynecological surgical setting. Identifying the sociotechnical factors that influence non-routine events are important in determining interventions that will combat the associated risks. Interventions focusing on teamwork, managing external interruptions, and coordinating equipment may have the greatest impact to reduce or eliminate NREs in gynecological surgeries.

Resident training in a teaching hospital: How do attendings teach in the real operative environment?

BACKGROUND: The study aim was to explore the nature of intraoperative education and its interaction with the environment where surgical education occurs. METHODS: Video and audio recording captured teaching interactions between colorectal surgeons and general surgery residents during laparoscopic segmental colectomies. Cases and collected data were analyzed for teaching behaviors and workflow disruptions. Flow disruptions (FDs) are considered deviations from natural case progression. RESULTS: Across 10 cases (20.4 operative hours), attendings spent 11.2 hours (54.7%) teaching, using directing (M = 250.1), and confirming (M = 236.1) most. FDs occurred 410 times, accounting for 4.4 hours of case time (21.57%). Teaching occurred with FD events for 2.4 hours (22.2%), whereas 77.8% of teaching happened outside FD occurrence. Teaching methods shifted from active to passive during FD events to compensate for patient safety. CONCLUSIONS: Understanding how FDs impact operative learning will inform faculty development in managing interruptions and improve its integration into resident education.

A Simulation-based, cognitive assessment of resident decision making during complex urinary catheterization scenarios.

BACKGROUND: This study explores general surgery residents' decision making skills in uncommon, complex urinary catheter scenarios. METHODS: 40 residents were presented with two scenarios. Scenario A was a male with traumatic urethral injury and scenario B was a male with complete urinary blockage. Residents verbalized whether they would catheterize the patient and described the workup and management of suspected pathologies. Residents' decision paths were documented and analyzed. RESULTS: In scenario A, 45% of participants chose to immediately consult Urology. 47.5% named five diagnostic tests to decide if catheterization was safe. In scenario B, 27% chose to catheterize with a 16 French Coude. When faced with catheterization failure, participants randomly upsized or downsized catheters. Chi-square analysis revealed no measurable consensus amongst participants. CONCLUSIONS: Residents need more training in complex decision making for urinary catheterization. The decision trees generated in this study provide a useful blueprint of residents' learning needs. SUMMARY: Exploration of general surgery residents' decision making skills in uncommon, complex urinary catheter scenarios revealed major deficiencies. The resulting decision trees reveal residents' learning needs.

Integrating Postoperative Feedback Into Workflow: Perceived Practices and Barriers.

OBJECTIVE: Previous studies have found that both resident and staff surgeons highly value postoperative feedback; and that such feedback has high educational value. However, little is known about how to consistently deliver this feedback. Our aim was to understand how often surgical residents should receive feedback and what barriers are preventing this from occurring. DESIGN: Surveys were distributed to resident and attending surgeons. Questions focused on the current frequency of postoperative feedback, desired frequency and methods of feedback, and perceived barriers. Quantitative data were analyzed with descriptive statistics, and text responses were examined using coding. SETTING: University-based general surgery department at a Midwestern institution. PARTICIPANTS: General surgery residents (n = 23) and attending surgeons (n = 22) participated in this study. RESULTS: Residents reported receiving and staff reported giving feedback for procedure-specific performance after 25% versus 34% of cases, general technical feedback after 36% versus 32%, and nontechnical performance after 17% versus 18%. Both perceived procedure-specific and general technical feedback should be given more than 80% of the time, and nontechnical feedback should happen for nearly 60% of cases. Verbal feedback immediately after the operation was rated as best practice. Both parties identified time, conflicting responsibilities, lack of privacy, and discomfort with giving and receiving meaningful feedback as barriers. CONCLUSIONS: Both resident and staff surgeons agree that postoperative feedback is given far less often than it should. Future work should study intraoperative and postoperative feedback to validate resident and attending surgeons' perceptions such that interventions to improve and facilitate this process can be developed.

Do resident's leadership skills relate to ratings of technical skill?

BACKGROUND: This study sought to compare general surgery research residents' survey information regarding self-efficacy ratings to their observed performance during a simulated small bowel repair. Their observed performance ratings were based on their leadership skills in directing their assistant. METHODS: Participants were given 15 min to perform a bowel repair using bovine intestines with standardized injuries. Operative assistants were assigned to help assist with the repair. Before the procedure, participants were asked to rate their expected skills decay, task difficulty, and confidence in addressing the small bowel injury. Interactions were coded to identify the number of instructions given by the participants to the assistant during the repair. Statistical analyses assessed the relationship between the number of directional instructions and participants' perceptions self-efficacy measures. Directional instructions were defined as any dialog by the participant who guided the assistant to perform an action. RESULTS: Thirty-six residents (58.3% female) participated in the study. Participants who rated lower levels of decay in their intraoperative decision-making and small bowel repair skills were noted to use their assistant more by giving more instructions. Similarly, a higher number of instructions correlated with lower perceived difficulty in selecting the correct suture, suture pattern, and completing the entire surgical task. CONCLUSIONS: General surgery research residents' intraoperative leadership skills showed significant correlations to their perceptions of skill decay and task difficulty during a bowel repair. Evaluating resident's directional instructions may provide an additional individualized intraoperative assessment metric. Further evaluation relating to operative performance outcomes is warranted.

Resident performance in complex simulated urinary catheter scenarios.

BACKGROUND: Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter-associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision-making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that during urinary catheterization, residents will make inconsistent decisions relating to catheter choices and clinical presentations. METHODS: Forty-five general surgery residents (postgraduate year 2-4) in Midwest training programs were presented with three of four urinary catheter scenarios of varying difficulty. Residents were allowed 15 min to complete the scenarios with five different urinary catheter choices. A chi-square test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision-making for each scenario. RESULTS: Eighty-two percent of residents performed scenario A; 49% performed scenario B; 64% performed scenario C, and 82% performed scenario D. For initial attempt for scenario A-C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, P's < 0.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, P < 0.01). Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (P < 0.001). Chi-square analyses showed no relationship between residents' first and subsequent catheter choices for each scenario (P's > 0.05). CONCLUSIONS: Evaluation of clinical decision-making shows that initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or training in clinical decision-making with regard to urinary catheter choices in residents.

Exploring hand coordination as a measure of surgical skill.

BACKGROUND: The study aim was to identify residents' coordination between dominant and nondominant hands while grasping for sutures in a laparoscopic ventral hernia repair procedure simulation. We hypothesize residents will rely on their dominant and nondominant hands unequally while grasping for suture. METHODS: Surgical residents had 15 min to complete the mesh securing and mesh tacking steps of a laparoscopic ventral hernia repair procedure. Procedure videos were coded for manual coordination events during the active suture grasping phase. Manual coordination events were defined as: active motion of dominant, nondominant, or both hands; and bimanual or unimanual manipulation of hands. A chi-square test was used to discriminate between coordination choices. RESULTS: Thirty-six residents (postgraduate year, 1-5) participated in the study. Residents changed manual coordination types during active suture grasping 500 times, ranging between 5 and 24 events (M = 13.9 events, standard deviation [SD] = 4.4). Bimanual coordination was used most (40%) and required the most time on average (M = 20.6 s, SD = 27.2), while unimanual nondominant coordination was used least (2.2%; M = 7.9 s, SD = 6.9). Residents relied on their dominant and nondominant hands unequally (P < 0.001). During 24% of events, residents depended on their nondominant hand (n = 120), which was predominantly used to operate the suture passer device. CONCLUSIONS: Residents appeared to actively coordinate both dominant and nondominant hands almost half of the time to complete suture grasping. Bimanual task durations took longer than other tasks on average suggesting these tasks were characteristically longer or switching hands required a greater degree of coordination. Future work is necessary to understand how task completion time and overall performance are affected by residents' hand utilization and switching between dominant and nondominant hands in surgical tasks.

Relationship Between Technical Errors and Decision-Making Skills in the Junior Resident.

OBJECTIVE: The purpose of this study is to coevaluate resident technical errors and decision-making capabilities during placement of a subclavian central venous catheter (CVC). We hypothesize that there would be significant correlations between scenario-based decision-making skills and technical proficiency in central line insertion. We also predict residents would face problems in anticipating common difficulties and generating solutions associated with line placement. DESIGN: Participants were asked to insert a subclavian central line on a simulator. After completion, residents were presented with a real-life patient photograph depicting CVC placement and asked to anticipate difficulties and generate solutions. Error rates were analyzed using chi-square tests and a 5% expected error rate. Correlations were sought by comparing technical errors and scenario-based decision-making skills. SETTING: This study was performed at 7 tertiary care centers. PARTICIPANTS: Study participants (N = 46) largely consisted of first-year research residents who could be followed longitudinally. Second-year research and clinical residents were not excluded. RESULTS: In total, 6 checklist errors were committed more often than anticipated. Residents committed an average of 1.9 errors, significantly more than the 1 error, at most, per person expected (t(44) = 3.82, p < 0.001). The most common error was performance of the procedure steps in the wrong order (28.5%, p < 0.001). Some of the residents (24%) had no errors, 30% committed 1 error, and 46 % committed more than 1 error. The number of technical errors committed negatively correlated with the total number of commonly identified difficulties and generated solutions (r (33) = -0.429, p = 0.021, r (33) = -0.383, p = 0.044, respectively). CONCLUSIONS: Almost half of the surgical residents committed multiple errors while performing subclavian CVC placement. The correlation between technical errors and decision-making skills suggests a critical need to train residents in both technique and error management.

Error tolerance: an evaluation of residents' repeated motor coordination errors.

BACKGROUND: The study investigates the relationship between motor coordination errors and total errors using a human factors framework. We hypothesize motor coordination errors will correlate with total errors and provide validity evidence for error tolerance as a performance metric. METHODS: Residents' laparoscopic skills were evaluated during a simulated laparoscopic ventral hernia repair for motor coordination errors when grasping for intra-abdominal mesh or suture. Tolerance was defined as repeated, failed attempts to correct an error and the time required to recover. RESULTS: Residents (N = 20) committed an average of 15.45 (standard deviation [SD] = 4.61) errors and 1.70 (SD = 2.25) motor coordination errors during mesh placement. Total errors correlated with motor coordination errors (r[18] = .572, P = .008). On average, residents required 5.09 recovery attempts for 1 motor coordination error (SD = 3.15). Recovery approaches correlated to total error load (r[13] = .592, P = .02). CONCLUSIONS: Residents' motor coordination errors and recovery approaches predict total error load. Error tolerance proved to be a valid assessment metric relating to overall performance.

Exploring Senior Residents' Intraoperative Error Management Strategies: A Potential Measure of Performance Improvement.

OBJECTIVE: The study aim was to determine whether residents' error management strategies changed across 2 simulated laparoscopic ventral hernia (LVH) repair procedures after receiving feedback on their initial performance. We hypothesize that error detection and recovery strategies would improve during the second procedure without hands-on practice. DESIGN: Retrospective review of participant procedural performances of simulated laparoscopic ventral herniorrhaphy. A total of 3 investigators reviewed procedure videos to identify surgical errors. Errors were deconstructed. Error management events were noted, including error identification and recovery. SETTING: Residents performed the simulated LVH procedures during a course on advanced laparoscopy. Participants had 30 minutes to complete a LVH procedure. After verbal and simulator feedback, residents returned 24 hours later to perform a different, more difficult simulated LVH repair. PARTICIPANTS: Senior (N = 7; postgraduate year 4-5) residents in attendance at the course participated in this study. RESULTS: In the first LVH procedure, residents committed 121 errors (M = 17.14, standard deviation = 4.38). Although the number of errors increased to 146 (M = 20.86, standard deviation = 6.15) during the second procedure, residents progressed further in the second procedure. There was no significant difference in the number of errors committed for both procedures, but errors shifted to the late stage of the second procedure. Residents changed the error types that they attempted to recover (χ25=24.96, p<0.001). For the second procedure, recovery attempts increased for action and procedure errors, but decreased for strategy errors. Residents also recovered the most errors in the late stage of the second procedure (p < 0.001). CONCLUSION: Residents' error management strategies changed between procedures following verbal feedback on their initial performance and feedback from the simulator. Errors and recovery attempts shifted to later steps during the second procedure. This may reflect residents' error management success in the earlier stages, which allowed further progression in the second simulation. Incorporating error recognition and management opportunities into surgical training could help track residents' learning curve and provide detailed, structured feedback on technical and decision-making skills.

Advanced Engineering Technology for Measuring Performance.

The demand for competency-based assessments in surgical training is growing. Use of advanced engineering technology for clinical skills assessment allows for objective measures of hands-on performance. Clinical performance can be assessed in several ways via quantification of an assessee's hand movements (motion tracking), direction of visual attention (eye tracking), levels of stress (physiologic marker measurements), and location and pressure of palpation (force measurements). Innovations in video recording technology and qualitative analysis tools allow for a combination of observer- and technology-based assessments. Overall the goal is to create better assessments of surgical performance with robust validity evidence.