The Operating Room as a Classroom: a New Approach to Skills Assessment and Training in Surgery

Introduction: Ensuring that trainees are graduated as competent, safe surgeons who can independently perform successful operations is a social obligation. Much of surgical technical training occurs in the operating room; as a result, enhancing training in this environment needs to be a priority. In this thesis, a comprehensive training approach, based on coaching principles, is described as a means to structure the experiential learning experience of training in the operating room.;Methods: Three main steps were required. Step 1: Design of an assessment methodology based on error analysis, as an adjunct to global skill assessment, to allow for comprehensive feedback. Step 2: Standardization of training content. For this, delineation of erroneous from adequate task execution was required, and causal relationships between errors and intraoperative injuries (events) needed identifying. Step 3: Design of a coaching intervention, based on observed operative performance, using established instructional approaches.;Results: (1) The generic error rating tool was based on four error modes attributed to nine laparoscopic tasks. Substantial construct validity evidence was gathered through applying the tool in video analyses of routine procedures. (2) In an international Delphi consensus, definitions and examples of errors and events were obtained. Further, evidence supporting the role of errors was obtained through reviewing 66 error-event patterns identified by video analysis of routine bariatric procedures. (3) The effectiveness of the coaching intervention was demonstrated in a randomized controlled design. Coached residents (n=9) scored significantly higher on a procedure-specific skill scale (BOSATS) and made fewer technical errors than conventionally trained residents (n=9) (BOSATS median 3.90 (i.q.r. 3.68-4.30) vs. 3.60, (2.98-3.70), P=0.017; technical error 10 (7-13) vs. 18 (13-21), P=0.003).;Conclusion: Designing training in a personalized fashion, following principles of coaching, can help structure experiential learning in the operating room, which leads to significantly enhanced skill acquisition in surgical training.