How good a surgeon are you? - Standardized formative assessment of surgical competence for ophthalmology residents in training.

The making of a trainee resident into a competent surgeon is challenging. The Accreditation Council for Graduate Medical Education in the United States mandates six core competencies for residents in training patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.[1] Although surgical competence is just one part of the vast skill set an ophthalmology resident is expected to acquire, it is unarguably the most important attribute that has a direct impact on patient outcome.

In several countries, ophthalmology residency programs mandate a minimum number for supervised and independent cataract and other ophthalmic surgeries (quantity), but more often than not, there are no specified standard measures to assess how well the surgeries are performed (quality). Ophthalmic surgical training in India is traditionally based on an apprenticeship model. Residents undertake 2–3 years of training and are awarded a postgraduate degree on the basis of an exit examination. However, the surgical skills are not formally assessed and do not form a prerequisite to exit residency. Furthermore, the surgical training grossly varies among different states and universities. There is an obvious lack of standardization in surgical training and objectivity in assessment and feedback.[234567]

The aim of assessment is to demonstrate learning (assessment of learning or summative assessment) or to facilitate learning (assessment for learning or formative assessment).[8] The goal of summative assessment is to evaluate learning at the end of an instructional unit, typically a residency exit examination, whereas the goal of a formative assessment is to provide ongoing feedback to improve learning.[8] Formative assessment helps the trainees identify their strengths and weaknesses and allows them to focus on skills that need enhancement.[8] Moreover, it helps the faculty recognize suboptimal performance and take remedial measures. An ideal system of surgical training must adopt an objective, transparent, and valid formative assessment that gives continuous feedback to the trainees.

There are several proposed methods of formative assessment of surgical skills. Cremers et al. developed the “Objective Assessment of Skills in Intraocular Surgery” to assess the residents' skills in cataract surgery, where an evaluator observes and provides an objective assessment of the surgical steps.[9] This can be used in conjunction with the “Global Rating Assessment of Skills in Intraocular Surgery” that allows the evaluator to assign scores based on a rubric.[10] Saleh described the “Objective Structured Assessment of Cataract Surgical Skill” (OSACSS) which stratifies phacoemulsification into twenty steps that are scored on a 5-point Likert scale.[11] The International Council of Ophthalmology (ICO) modified OSACSS to include a Dreyfus-inspired model of skill acquisition.[12] The ICO's Ophthalmology Surgical Competency Assessment Rubric (ICO-OSCAR) is designed by a panel of international experts to facilitate assessment and acquisition of surgical skills. Surgical procedures are described in individual steps; each step is evaluated on a scale based on competence, graded as a novice, a beginner, an advanced beginner, or a competent surgeon. The requirement for the level of performance to achieve each grade in each step is clearly described. The assessor scores the observed performance either manually or electronically. The completed OSCAR is then discussed with the trainee at the end of the surgery to provide timely, structured, and specific feedback.[121314]

This type of assessment tool serves three distinct purposes (1) It minimizes subjectivity by clearly defining the skills that must be observed at each level of proficiency; (2) The rubric clearly states what is expected of the trainee to attain competence at each level and thus can be used for both assessment and teaching; and (3) Self-assessment by reflective practice is possible when the trainees' surgical procedures are recorded.[131415] Currently, assessment tools are available for phacoemulsification, extracapsular cataract surgery, small incision cataract surgery, lateral tarsal strip surgery, strabismus surgery, trabeculectomy, and pediatric cataract surgery.[2121516171819] Similar tools are being developed for other ophthalmic procedures including panretinal photocoagulation, corneal transplant, and vitrectomy. These tools are subject to constant evolution, and one such example is the modified OSCAR by Farooqui and associates that can be used in a wetlab situation, the results of which are reported in the current issue of Indian Journal of Ophthalmology.[20]

Irrespective of whether or not the formative assessment of surgical skills becomes an integral part of our formal residency training framework, it would be in the interest of our trainees and trainers that we adopt the OSCAR tools to train and assess our residents. If adequately developed to cover the spectrum of other commonly performed subspecialty surgical procedures, such tools can add immense value to our fellowship surgical training as well and possibly help create a generation of objectively trained surgeons.