Development and Validation of Instrument for Operative Competency Assessment in Selective Neck Dissection.

BACKGROUND: Instruments to assess surgical skills have been validated for several key indicator procedures in otolaryngology. Selective neck dissection is a core procedure for which trainees must integrate knowledge of complex head and neck anatomy with technical surgical skills. An instrument for assessment of surgical performance in selective neck dissection has not been previously developed. The objective of the current study is to develop and validate an instrument for assessing surgical competency for level II-IV selective neck dissection. DESIGN: A Delphi working group comprised of 23 fellowship trained head and neck surgeons from 17 institutions was assembled. The modified Delphi method encompassed a 3-step process, including 2 anonymous voting rounds to successively refine individual items and establish levels of consensus. Thresholds for achieving strong consensus, at >80% agreement, were determined a priori. The resulting instrument was subsequently validated in a prospective cohort of 17 resident surgeons, spanning postgraduate year 1 to 5 training experience. Participants were asked to perform a level II-IV selective neck dissection on fresh-frozen cadaveric specimens. Performance was scored by 2 independent, blinded observers using the devised instrument and construct validity was assessed. RESULTS: Through the modified Delphi process a final list of 30 items, considered to be the most essential items for achieving the goals of a level II-IV selective neck dissection, was developed. Construct validity was supported by a positive association between instrument scores compared to both resident postgraduate year level and number of head and neck rotations completed. CONCLUSION: The development and validation of a novel instrument for assessment of surgical competency in level II-IV selective neck dissection, a key indicator case in otolaryngology, is described. This new instrument may be used to provide objective feedback on overall and task-specific competency to identify surgical deficiencies and offer granular feedback to enhance surgical training.

Assessment of operative competency for thyroidectomy: Comparison of resident self-assessment vs attending surgeon assessment.

BACKGROUND: Self-awareness of skill, essential for progression as a surgeon, has direct bearing on postresidency practice; however, studies have supported that residents achieve self-perceived competence later than believed by program directors. This study compares residents' self-perception of operative competency to attending surgeon's evaluation using Computer Enhanced Visual Learning, a validated online hemithyroidectomy-specific assessment tool. METHODS: Eleven otolaryngology-Head and Neck Surgery (HNS) residents completed a preoperative module and postoperative survey, later reviewed by an attending surgeon. Eighty-three performances were assessed for inter-rater reliabilities of key surgical steps. RESULTS: Almost perfect agreement (Kappa = 0.81-1.00) was shown in 11 of 18 parameters. Substantial agreement (Kappa = 0.61-0.80) was demonstrated in the remaining seven parameters. CONCLUSIONS: Otolaryngology-HNS trainees have high self-awareness of their performance at each step in a hemithyroidectomy. Standardized assessment tools can allow for documentation of procedural performance and serve as guides for improvement. This is the only study to examine otolaryngology-HNS trainees' self-perceived skill compared to an attending surgeon's assessment for hemithyroidectomy.

Decreasing rates of axillary lymph node dissections over time: Implications for surgical resident exposure and operative skills development.

BACKGROUND: Sentinel lymph node biopsy has supplanted axillary lymph node dissection (ALND) in clinically node-negative breast cancer and select node-positive disease. We hypothesized a decreasing rate of both ALND and resident exposure over time. METHODS: We identified women with clinical Stage I-III breast cancer in the National Cancer Data Base (2004-2014). Adjusted multivariate logistic regression was used to estimate the effect of various factors on receipt of ALND. Yearly procedural rates for residents were extracted from surgical case log reports for comparison against procedural rates. RESULTS: 1,131,363 patients were identified; 255,306 received ALND, 876,057 underwent non-ALND management. ALND rates declined from 2004 (32%) to 2014 (16%, p < 0.001), with the largest decline occurring between 2010 and 2011 (24%-20%). After adjustment, this effect was maintained, with ALND rates decreasing with each additional year (OR = 0.90, 95% CI 0.89-0.90). Resident procedure volumes similarly declined from 1999 to 2017 (p < 0.001). CONCLUSIONS: Significant declines in both ALND rates and procedural volume in residency may impact outcomes, as ALNDs are being performed in ever more challenging oncologic scenarios by potentially less-experienced surgeons.

Case Reporting, Competence, and Confidence: A Discrepancy in the Numbers.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) continues to play an integral role in accreditation of surgical programs. The institution of case logs to demonstrate competency of graduating residents is a key component of evaluation. This study compared the number of vascular cases a surgical resident has completed according to the ACGME operative log to their operative proficiency, quality of anastomosis, operative experience, and confidence in both a simulation and operative setting. MATERIALS AND METHODS: General surgery residents ranging from PGY 1 to 5 participated in a simulation laboratory in which they completed an end-to-side vascular anastomosis. Each participant was given a weighted score based on technical proficiency and anastomosis quality using a previously validated Global Rating Scale (Duran et al, 2014). These scores were correlated to the General Surgery Milestones. Participants completed preoperative and postoperative surveys assessing resident operative experience using the 4-level Zwisch scale (DaRosa et al., 2013), confidence with vascular procedures and confidence performing simulated anastomoses. Confidence was assessed on a scale from 1 to 9 (not confident to extremely confident). Case logs were recorded for each participant. An IRB approved questionnaire was distributed to assess preoperative and postoperative roles of both the resident physician and faculty, with a defined goal. Univariate and multivariate analysis was performed. RESULTS: Twenty-one general surgery residents were evaluated in the simulation laboratory and 8 residents were assessed intraoperatively. The residents were evenly distributed throughout clinical years. Groups of residents were divided into quartiles based upon the number of vascular cases recorded in the ACGME database. No correlation was found between number of cases, Milestones score and the weighted score (p = 0.94). No statistical significance was found between confidence and quality of anastomosis (p = 0.1). Resident operative experience per the Zwisch scale was categorized most commonly as "Smart Help" by both the trainee and attending surgeon, despite mean resident confidence ratings of 6.67 (± 1.61) with vascular procedures. CONCLUSIONS: ACGME case logs, which are utilized to assess readiness for completion of general surgery residency, may not be indicative of a resident's operative competency and technical proficiency. Confidence is not correlated with technical ability. Faculty and resident insight as to their role in a procedure differ, as faculty feel that they are providing less help than the resident perceives. Careful examination of resident operative technique is the best measure of competency.

Performance Assessment for Mastoidectomy.

Objective The aim of this report is to provide a review of the current literature for assessment of performance for mastoidectomy, to identify the current assessment tools available in the literature, and to summarize the evidence for their validity. Data Sources The MEDLINE database was accessed via PubMed. Review Methods Inclusion criteria consisted of English-language published articles that reported use of a mastoidectomy performance assessment tool. Studies ranged from 2007 to November 2015 and were divided into 2 groups: intraoperative assessments and those performed with simulation (cadaveric laboratory or virtual reality). Studies that contained specific reliability analyses were also highlighted. For each publication, validity evidence data were analyzed and interpreted according to conceptual definitions provided in a recent systematic review on the modern framework of validity evidence. Conclusions Twenty-three studies were identified that met our inclusion criteria for review, including 4 intraoperative objective assessment studies, 5 cadaveric studies, 10 virtual reality simulation studies, and 4 that used both cadaveric assessment and virtual reality. Implications for Practice A review of the literature revealed a wide variety of mastoidectomy assessment tools and varying levels of reliability and validity evidence. The assessment tool developed at Johns Hopkins possesses the most validity evidence of those reviewed. However, a number of agreed-on specific metrics could be integrated into a standardized assessment instrument to be used nationally. A universally agreed-on assessment tool will provide a means for developing standardized benchmarks for performing mastoid surgery.

Construct validity of the ovine model in endoscopic sinus surgery training.

OBJECTIVES/HYPOTHESIS: To demonstrate construct validity of the ovine model as a tool for training in endoscopic sinus surgery (ESS). STUDY DESIGN: Prospective, cross-sectional evaluation study. METHODS: Over 18 consecutive months, trainees and experts were evaluated in their ability to perform a range of tasks (based on previous face validation and descriptive studies conducted by the same group) relating to ESS on the sheep-head model. Anonymized randomized video recordings of the above were assessed by two independent and blinded assessors. A validated assessment tool utilizing a five-point Likert scale was employed. Construct validity was calculated by comparing scores across training levels and experts using mean and interquartile range of global and task-specific scores. Subgroup analysis of the intermediate group ascertained previous experience. Nonparametric descriptive statistics were used, and analysis was carried out using SPSS version 21 (IBM, Armonk, NY). RESULTS: Reliability of the assessment tool was confirmed. The model discriminated well between different levels of expertise in global and task-specific scores. A positive correlation was noted between year in training and both global and task-specific scores (P < .001). Experience of the intermediate group was variable, and the number of ESS procedures performed under supervision had the highest impact on performance. CONCLUSIONS: This study describes an alternative model for ESS training and assessment. It is also the first to demonstrate construct validity of the sheep-head model for ESS training.