PUBLISHED WORKS AND NARRATIVES
4. Resident focus groups: how do surgical residents perceive the education they receive from surgeon teachers?
2.5 e Considerations regarding the observational communication and overlay development studies
The intraoperative teaching techniques observed during the observational study included the use of multiple non-technical skills such as multiple types of communication, motivation of the trainee, leadership, resource management in the OR, decision-making, teamwork, and
situational awareness, and the provision of feedback, each of which have been found to play significant roles in surgeons’ and trainees’ overall performance during surgery.12-14 Each of the themes that arose during the analysis of the observational communication study aligned with one or more competency roles that are designated in the CanMEDS framework and other frameworks such as the ACGME. The importance of the intraoperative instruction trainees
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receive is paramount when considering whether trainees will meet and/or exceed critical demonstrable competencies as they progress through training. A breakdown in one or more non-technical skills during surgical procedures can lead to medical errors, thereby
compromising patient safety and outcomes while hindering the educational process. Thus far, the development, use, and evaluation of the alphanumeric overlay as a teaching tool for
laparoscopic cases is promising, especially for teaching junior-level residents and other trainees learning a new surgical procedure. This overlay has the potential to improve efficiency of laparoscopic teaching cases and ultimately reduce the frequency of medical errors in the intraoperative teaching environment.
The role that non-technical skills play during surgical training and in the acquisition and performance of technical surgical skills is still poorly understood and is deserving of further study. A systematic review of the impact of non-technical skills on technical performance in surgery found just 28 reports of studies designed to assess the impact of surgeons’ non-
technical skills on technical skill performance in either the simulated surgical setting and/or the OR.15 The majority of the studies in the review examined the impact of just one non-technical skill on technical performance. These were assessed by tools ranging from those with
demonstrated reliability and validity to scales designed specifically for the study that had no validity evidence. The review showed that, indeed, failures in non-technical skills appear to be associated with a higher rate of technical errors.
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Three major taxonomies have been developed to evaluate non-technical skills: the Non- Technical Skills for Surgeons (NOTSS) tool16, the Oxford NOTECHS (Non-TECHnical Skills)17, and the Observational Teamwork Assessment for Surgery (OTAS).18 Each of these tools’ constructs are related to aspects of the entire OR team and do not focus specifically on the surgeon or learner, but instead provide comprehensive information related to system-wide actions and teamwork-associated behaviors. These tools are primarily designed to evaluate entire surgical procedures and are not task-specific; and although they are not inherently feasible for quick evaluation of individual surgical skills, these tools may still have an important role in evaluating what occurs during teaching throughout an entire case. Despite the lack of valid, reliable, and feasible tools designed for evaluating distinctive non-technical skills and behaviours (e.g., motivation, feedback, communication) in the intraoperative setting, it is critical that the non- technical skills surgical educators use during the teaching process be considered when
developing and/or revising surgical training curricula, especially as the new competency-based frameworks become integrated into training programs.
Our research team is encouraged by the findings of these studies, and we hope to integrate the alphanumeric overlay within our institution so that it may eventually become a mainstay of the curriculum for minimally-invasive surgical training, with the potential for initial use in simulated laparoscopic training, followed by eventual regular use in the OR. Although our results are limited to a small sample size within a single centre, additional research, perhaps via a multicentre study, may allow us to begin to generalise our findings, with the potential of the overlay to be included in curricula, especially with the development of an assessment
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component, which is a future objective of this research. Furthermore, the alphanumeric grid overlay concept has the potential to be transferred to other types of minimally-invasive surgical training, such as robotics and other surgical approaches that involve the use of screens for visual guidance, such as endoscopic and arthroscopic surgery.
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2.5f References for sections 2.5a-2.5e
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5. Blom EM, Verdaasdonk EG, Stassen LP, et al. Analysis of verbal communication during teaching in the operating room and the potential for surgical training. Surg Endosc, 2007, 21(9):1560-1566.
6. Claridge JA, Calland JF, Chandrasekhara V, et al. Comparing resident measurements to attending surgeon self-perceptions of surgical educators. Am J Surg, 2003, 185(4):323-327. 7. Lingard L, Reznick R, Espin S, Regehr, G. & DeVito I. Team communications in the operating
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10. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-334.
11. Yule S, Flin R, Paterson-Brown S & Maran N. Non-technical skills for surgeons in the operating room: A review of the literature. Surgery, 2005, 139(2): 140-149.
12. Hull L, Arora S, Aggarwal R, Darzi A, Vincent C, Sevdalis N. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg. Feb
2012;214(2):214-230.
13. Sharma B, Mishra A, Aggarwal R, Grantcharov TP. Non-technical skills assessment in surgery. Surg Oncol. Sep 2010;20(3):169-177.
14. Beard JD, Marriott J, Purdie H, Crossley J. Assessing the surgical skills of trainees in the operating theatre: a prospective observational study of the methodology. Health Technol Assess. Jan 2011;15(1):i-xxi, 1-162.
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16. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons' non-technical skills. Med Educ. Nov 2006;40(11):1098-1104.
17. Sevdalis N, Davis R, Koutantji M, Undre S, Darzi A, Vincent CA. Reliability of a revised NOTECHS scale for use in surgical teams. Am J Surg. Aug 2008;196(2):184-190.
18. Hull L, Arora S, Kassab E, Kneebone R, Sevdalis N. Observational teamwork assessment for surgery: content validation and tool refinement. J Am Coll Surg. Feb 2011;212(2):234-243 e231-235.
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