The past century has seen an enormous rise in new surgical procedures. The general surgery landscape has changed markedly, from predominantly open procedures to laparoscopic and now robotic surgery. Surgical training has been far slower to adjust to change, as evidenced by the haphazard method of introduction of laparoscopic surgery. The introduction of laparoscopy was marked by procedures being performed by surgeons without a structured fellowship training program, in addition to questionable legitimacy of procedures due to the lack of supportive data.
New surgical methods and new technologies, such as robotic surgery, have been accompanied by a greater emphasis upon educational efforts prior to surgical "practice". Capabilities such as dual consoles to maximise the teaching potential of the platform in addition to exposure during training lends some recognition to this modern requirement.
To date, the most common methods of assessing a surgeon for accreditation by an institution have relied upon surrogate competency measures. The two most common are Years of experience
Refinement of existing surgical procedures is ubiquitous by surgeons and device technology developers alike. However, the past half-century has seen an unprecedented rise in new operations. In general surgery, the development of laparoscopy has led to a legion of new ways to perform existing procedures and a paradigm shift in skillset, almost unrecognisable to that of a traditionally-trained "open" surgeon. In hindsight, the methodology of learning laparoscopic surgery was at best haphazard; at worst, dangerous with a concomitant rise in morbidity and mortality.
Similarly, the introduction of robotic surgery has shown benefits of shortened hospital stays and complication rates, tempered by increased intraoperative times, cost and increased training burden of the new technique.
The belated introduction of structured courses such as Fundamentals of Laparoscopic Surgery course
Proceduralists benefit from standardised, validated curriculums for teaching competence focused upon specific skills.
The creation of a formal, structured curriculum for a novel surgical procedure must be adjusted to suit the local environment. The curriculum must be structured to suit local nuances of device availability, preference of technique, and patient demographic. Validating the content of a curriculum towards a particular region is often conducted via Delphi methodology similar to above, with the expert group derived entirely from the defined area.
One of the most powerful aspects of a validated curriculum is the ability to discern a novice from an expert surgeon. The definitions of these are highly debatable and is most notably determined by surrogate competency markers such as case-volume load or time-based (years in practice). There is a move towards standardised, reproducible content assessment, which often requires the use of a simulator. Via direct observation or retrospective video review of a surgical operation upon a simulator, a trained assessor can rate them upon predefined metrics, utilising construct validity to determine whether the assessment score relates to the allocated group of experts or surgeons. The preferred approach of a simulator removes the requirement for statistical adjustment for patient comorbidities such as body habitus, previous surgery or adhesions. However, its transferability to "real-life surgery" is an extra consideration that often needs to be validated prior to use as a high-stakes assessment methodology. Defining criteria for credentialing to determine "expert status" utilising consensus methodology has been applied in robotic
The determination of a curriculum-based assessment for novel surgical procedures is an exemplary modality of reproducible, quality assessment. The rise of high-stakes assessment requires greater rigour in the development of the underlying curriculum with which surgeons are being trained to ensure competency upon the simulator as well as ensuring patient safety. Our paper describes the key educational and clinical concerns regarding the development of construct and content validity as well as components of transferability for assessment. Future assessment of surgeons in novel surgical procedures will likely require credentialing bodies to be cognizant of similar considerations of defensible curricular and assessment development.
The authors declare that they have no conflict of interest.