What are the learning objectives in surgical training - a systematic literature review of the surgical competence framework.

OBJECTIVE: To map the landscape of contemporary surgical education through a competence framework by conducting a systematic literature review on learning outcomes of surgical education and the instructional methods applied to attain the outcomes. BACKGROUND: Surgical education has seen a paradigm shift towards competence-based training. However, a gap remains in the literature regarding the specific components of competency taught and the instructional methods employed to achieve these outcomes. This paper aims to bridge this gap by conducting a systematic review on the learning outcomes of surgical education within a competence framework and the instructional methods applied. The primary outcome measure was to elucidate the components of competency emphasized by modern surgical curricula. The secondary outcome measure was to discern the instructional methods proven effective in achieving these competencies. METHODS: A search was conducted across PubMed, Medline, ProQuest Eric, and Cochrane databases, adhering to PRISMA guidelines, limited to 2017-2021. Keywords included terms related to surgical education and training. Inclusion criteria mandated original empirical studies that described learning outcomes and methods, and targeted both medical students and surgical residents. RESULTS: Out of 42 studies involving 2097 participants, most concentrated on technical skills within competency-based training, with a lesser emphasis on non-technical competencies. The effect on clinical outcomes was infrequently explored. CONCLUSION: The shift towards competency in surgical training is evident. However, further studies on its ramifications on clinical outcomes are needed. The transition from technical to clinical competence and the creation of validated assessments are crucial for establishing a foundation for lifelong surgical learning.

Measuring Competency: Improving the validity of your procedural performance assessments.

Objective: The objective of the study was to compare the use of ordinal scales and interval scales for capturing surgical competency information for general surgeons performing 3 complex trauma procedures. Background: Surgical performance assessment is typically captured using nonparametric data (eg, checklists) that do not support inferential analyses. Interval scales support parametric analyses that are essential for determining competency. We compared assessment outcomes for surgeons performing 3 complex trauma procedures using ordinal and interval scales. Methods: All participants were board-certified or eligible general surgeons. Each participant was assessed by an experienced trauma surgeon while performing 3 trauma procedures on cadavers. All assessors completed a rigorous assessment certification process. We calculated descriptive statistics to examine the differences between interval (parametric) and ordinal (nonparametric) outcomes. Results: Ordinal scales overestimated competence in up to 100% of the participants and did not identify specific performance gaps. Interval scales provided more granularity and identified specific capability gaps. Conclusions: Imprecise instrumentation conveys a false sense of competence and deprives surgeons of opportunities to close capability gaps. Measuring discrete procedural components with interval scales provides a more precise measurement of surgical competency.

The entrustable professional activities of laparoscopic surgery: moving toward an integrated training model.

BACKGROUND: Entrustable Professional Activities (EPAs) provide the opportunity to integrate multiple competencies into meaningful units that facilitate curriculum development and assessment design. As part of the process of reviewing and enhancing the Fundamentals of Laparoscopic of Surgery (FLS) program, we used the concept of EPAs to create a framework of reference that articulates a contemporary definition of Laparoscopic Surgery (LS). METHODS: The framework of reference of LS was created with data gathered from a literature review and during series of educational retreats with subject matter experts (SMEs). Various activities were implemented during these retreats to develop the LS EPAs, their constitutive competencies, and related observable behaviors. RESULTS: Ten EPAs and associated competency descriptors (articulated as observable behaviors) specific to LS were identified. In addition, knowledge areas were associated to each EPA. DISCUSSION: A comprehensive list of EPAs for LS were identified. These EPAs will be used in the development and update of the FLS program. Further, they can be used to guide the development of curriculum, clinical teaching, and assessment in any surgical program with a laparoscopic training component. They are applicable to any level of training by defining the expected observable behaviors associated with a given level of expertise. These fundamental aspects of LS provide a common framework of reference across different surgical specialties.

Construção de simulador laparoscópico de média fidelidade e avaliação da curva de aprendizagem / Construction of a medium fidelity laparoscopic simulator and evaluate the learning curve assessment

Introdução: Nos cursos de graduação em medicina, a simulação realística está sendo aplicada, cada vez mais, como um meio de propiciar aos estudantes e aos médicos o desenvolvimento de competências técnicas por meio da repetição de tarefas, realizadas em ambiente controlado, não comprometendo a segurança do paciente. Objetivo: Este estudo teve como objetivo construir um simulador laparoscópico de média fidelidade e avaliar a curva de aprendizagem gerada pelo treinamento de estudantes e de médicos residentes de cirurgia geral. Método: Após a construção do simulador laparoscópico de média fidelidade, alunos do 3º e 4º anos de graduação, do Curso de Medicina da Universidade José do Rosário Vellano (UNIFENAS), campus Alfenas, e médicos residentes do Hospital Universitário Alzira Velano, foram submetidos a treinamento e suas curvas de aprendizagem foram avaliadas pela determinação do tempo de realização da tarefa e dos erros cometidos. Resultados: Participaram da pesquisa 27 sujeitos, de ambos os sexos (70% mulheres), sendo sete médicos residentes e 20 alunos do 5º ao 8º período do curso de medicina. A manufatura do simulador de média fidelidade foi viabilizada a um custo de R$ 300,00 por unidade. Os alunos que participaram previamente de ligas acadêmicas de cirurgia apresentaram menor tempo do primeiro teste em relação aos que não participaram (372,9 ± 89,1 vs. 259,0 ± 90,5 com p=0,032). Da mesma maneira, o número de repetições para atingir 90% do melhor escore foi inferior (7,0 ± 4,6 vs. 11,9 ± 1,7 com p=0,013). A intenção de seguir carreira cirúrgica também se mostrou associada à melhor pontuação no primeiro teste (282,9 ± 78,2 vs. 406,9 ± 87,6 com p=0,011) e menor número de repetições para atingir 90% do melhor escore (8,8 ± 4,1 vs. 12,4 ± 0,8 com p=0,017). Conclusão: O simulador laparoscópico possibilitou que todos os participantes tivessem uma melhora progressiva nos resultados da pontuação e redução do tempo de execução da tarefa, durante as repetições. Os alunos com interesse na área cirúrgica e que participaram de ligas acadêmicas apresentaram melhor rendimento na curva de aprendizagem. Estes achados, aliados ao baixo custo de produção do equipamento, revelam sua potencialidade como ferramenta de treinamento de habilidades cirúrgicas bem como apontam a necessidade de incorporação de novas tarefas ao simulador

Introduction: In undergraduate medical schools, realistic simulation has been applied more and more as a means of providing students and physicians with the development of technical skills through task repetition, performed in a controlled environment, without compromising the patient's safety. Objective: This study aimed to build a medium fidelity laparoscopic simulator and evaluate the learning curve generated by the training of general surgery students and residents. Method: After the construction of the medium fidelity laparoscopic simulator, 3rd and 4th year undergraduate students of José do Rosário Vellano University (UNIFENAS) School of Medicine, campus Alfenas, and resident doctors at Alzira Velano University Hospital, underwent training and their learning curve were evaluated by the time taken to perform the task and the mistakes made. Results: Twenty-seven subjects of both sexes (70% women) participated in the research, of which seven were residents and 20 were students between 5th to 8th semesters of medical school. The manufacture of the medium fidelity simulator was made possible at a cost of R$300.00 per unit. Students who previously participated in surgery academic leagues took less time in the first test compared to those who did not participate (372.9 ± 89.1 vs 259.0 ± 90.5 where p=0.032). Likewise, the number of repetitions needed to reach 90% of the best score was lower (7.0 ± 4.6 vs 11.9 ± 1.7 where p=0.013). The intention to follow a surgical career also proved to be associated with a better score on the first test (282.9 ± 78.2 vs 406.9 ± 87.6 where p=0.011) and a lower number of repetitions needed to reach 90% of the best score (8.8 ± 4.1 vs 12.4 ± 0.8 with p=0.017). Conclusion: The laparoscopic simulator allowed all participants to have a progressive improvement in scoring results and reduced task execution time during repetitions. Students interested in the surgical area and who participated in academic leagues showed better performance in the learning curve. These findings, sided with the equipment's low production cost, reveal its potential as a surgical skill training tool, as well as indicate the need of incorporating new tasks into the simulator

Video-Rated Performance Assessment of Simulated Laparoscopic Sleeve Gastrectomy: Validation of a Sleeve Gastrectomy Rating Scale.

PURPOSE: The global rise in obesity has been accompanied by widespread uptake of the procedure of laparoscopic sleeve gastrectomy. Despite this, the key components for performance assessment have not been standardized for this procedure. The aim of this study was to develop and demonstrate the validity of a Sleeve Objective Structured Assessment of Technical Skill (SOSATS) scale for learning the procedure of laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: The SOSATS evaluation tool was based upon critical steps of the LSG procedure. Both the SOSATS and the Global Rating Scale (GRS) component of the Objective Structured Assessment of Technical Skill (OSATS) tools were utilized in a prospective single-blinded observational study design of 26 video recordings of surgeons performing sleeve gastrectomies using a novel simulation. The surgeons were allocated into "novice" or "experienced" groups dependent on case-volume criteria. Surgical performance was assessed using both the GRS and SOSATS scales by blinded assessors of the video recordings. RESULTS: Face and content validity were demonstrated for key components of the simulated model. An overall positive correlation was established inferring concurrent validity between the accepted OSATS Global Rating Scale against the SOSATS procedural scale. Construct validity was established for a number of areas of the SOSATS scale. CONCLUSION: The SOSATS scale is shown to exhibit construct and concurrent validity in the simulated setting for the procedure of sleeve gastrectomy. Utilizing this scale to review surgical performance is potentially feasible and reliable but would require further research prior to use in high-stakes assessment processes such as credentialing.

Crowdsourced Assessment of Surgical Skill Proficiency in Cataract Surgery.

OBJECTIVE: To test whether crowdsourced lay raters can accurately assess cataract surgical skills. DESIGN: Two-armed study: independent cross-sectional and longitudinal cohorts. SETTING: Washington University Department of Ophthalmology. PARTICIPANTS AND METHODS: Sixteen cataract surgeons with varying experience levels submitted cataract surgery videos to be graded by 5 experts and 300+ crowdworkers masked to surgeon experience. Cross-sectional study: 50 videos from surgeons ranging from first-year resident to attending physician, pooled by years of training. Longitudinal study: 28 videos obtained at regular intervals as residents progressed through 180 cases. Surgical skill was graded using the modified Objective Structured Assessment of Technical Skill (mOSATS). Main outcome measures were overall technical performance, reliability indices, and correlation between expert and crowd mean scores. RESULTS: Experts demonstrated high interrater reliability and accurately predicted training level, establishing construct validity for the modified OSATS. Crowd scores were correlated with (r = 0.865, p < 0.0001) but consistently higher than expert scores for first, second, and third-year residents (p < 0.0001, paired t-test). Longer surgery duration negatively correlated with training level (r = -0.855, p < 0.0001) and expert score (r = -0.927, p < 0.0001). The longitudinal dataset reproduced cross-sectional study findings for crowd and expert comparisons. A regression equation transforming crowd score plus video length into expert score was derived from the cross-sectional dataset (r2 = 0.92) and demonstrated excellent predictive modeling when applied to the independent longitudinal dataset (r2 = 0.80). A group of student raters who had edited the cataract videos also graded them, producing scores that more closely approximated experts than the crowd. CONCLUSIONS: Crowdsourced rankings correlated with expert scores, but were not equivalent; crowd scores overestimated technical competency, especially for novice surgeons. A novel approach of adjusting crowd scores with surgery duration generated a more accurate predictive model for surgical skill. More studies are needed before crowdsourcing can be reliably used for assessing surgical proficiency.

Evaluation of tools to assess operative competence in endovascular procedures: a systematic review.

BACKGROUND: With an increase in the use of endovascular interventions as an alternative to open surgery and the unique technical skills required, current methods for assessing the competence of vascular surgery trainees may not be optimal, suggesting a need for a shift in assessment modalities. We conducted this systematic review to explore current assessment methods used in vascular surgery training to assess competence specific to endovascular procedures. METHODS: A comprehensive literature search was performed with a structured search strategy using terms focusing on endovascular procedures and assessment. Inclusion and exclusion criteria were used in order to screen for suitable articles. RESULTS: We identified 54 articles that satisfied the inclusion criteria. These included a single randomized controlled trial, a single systematic review, a single narrative review and a single literature review, with the vast majority having level 2 evidence. Global rating scales, proficiency assessments and written/oral examinations were described as standard current assessment tools. These modalities lack reproducibility and objectivity, neglecting the needs of assessment of endovascular procedures requiring specialized decision making and finger dexterity. Novel methods such as high fidelity simulation and virtual reality promote reproducible and objective assessment methods in the context of endovascular surgery, and have a promising future. CONCLUSION: While current assessment methods in vascular surgery are widely supported the changing skills required of a vascular surgery trainee warrants a shift in assessment modalities to better align to these requirements. High fidelity simulations show promise, although they require more extensive research to understand their relative merits.

How to stich? 90 degrees: The perfect angle.

OBJECTIVE: This is a discussion about correct suturing techniques and implications that follow inappropriate suturing. We deconstruct the suturing needle angles and methods to be adopted to acquire the perfect needle angle to the tissue being sutured. A study of angles confirms that 90° is perceptible to the naked eye and easy to identify, making it an appropriate foundation to explain, communicate and teach the concepts in the wet-lab and the operating room. BACKGROUND: There is a lack of robust teaching regarding entry of the needle orthogonal to the tissue planes. In addition, objective methods of assessing angles of the needle relative to the tissue and consequences of inaccuracy are lacking. The authors aim to deconstruct the steps of suturing with the aim of demonstrating ninety degrees is the perfect suturing angle. STUDY DESIGN: We conducted a study to identify 90° (the perfect suturing angle) as an angle easy to identify with the naked eye. Angles from 86° to 94° and 41° to 49° were printed and presented to volunteers with the instruction to identify the angles of 90° and 45°. RESULTS: Fifty-one volunteers replied to the 90° angle study and sixty-five volunteers replied to the 45° study. 92% correctly identified at least one 90° angle and 72% identified both the 90° angles. 63% identified at least one 45° angle and only 27% identified both the 45° angles presented to them. This supported our hypothesis that 90° is an angle that is readily identifiable to the human eye. CONCLUSIONS: Objective assessment of surgical skills and training should focus on the basic needle skills with particular emphasis on suturing angles, progressing to higher skills using low and intermediate fidelity models and correlating practice alongside the trainees' operative progress.

Path on the management of surgical graded and refined management based on information technology / 中华医院管理杂志

The authors attempted to use information technology in hierarchical management on clinician′s surgical authority. By means of a hierarchical surgery catalogue database, clinicians′ surgical authority is subject to by-level IT-based approval, and such authorities as clinician′s surgical medical advice, application for surgery, and approval of special surgeries are regulated. Thanks to multi-dimensional objective data, clinicians′surgical competence is subject to a dynamic evaluation, hierarchical authorization and reauthorization. These measures further standardize the behavior of the surgeons, and rule out unauthorized operations, thus improving fine management of surgeries and ensuring patient safety.

Evaluación de competencias quirúrgicas de los egresados del programa de formación en otorrinolaringología de la Universidad de Chile / Surgical skills evaluation of the graduates from the training program in otorhinolaryngology of the University of Chile

RESUMEN Introducción En Chile, la especialidad de otorrinolaringología (ORL) es impartida por 4 universidades. La acreditación de los programas de formación de especialistas está a cargo de la Agencia Acreditadora de Programas de Posgrado de Especialidades en Medicina y Centros Formadores de Médicos Especialistas (APICE). Para la especialidad de ORL se propone una lista de cirugías y un número mínimo a realizar durante sus años de formación, esta recomendación surgió del análisis de un grupo de expertos. Objetivo Evaluar número y tipos de cirugías realizadas por egresados del Programa de Formación en ORL de la Universidad de Chile y comparar estos resultados con los criterios recomendados por APICE. Material y método Se revisaron los portafolios quirúrgicos de los egresados del programa de ORL entre los años 2006-2016 entregados en la Escuela de Posgrado de la Universidad de Chile. Se registró nombre de cirugía, rol en la cirugía (cirujano o ayudante), unidad académica, año de residencia en que se realizó y año de egreso. Resultados Se revisaron 77 portafolios, de los cuales se excluyeron 11 (1 por no tener examen rendido, 1 por entregar datos mal registrados y 9 por no especificar rol en cirugía), por lo que se tabularon 66. Ninguno de los egresados cumple con las recomendaciones APICE. Conclusiones La Universidad de Chile posee el programa de formación en ORL más antiguo y que aporta la mayor cantidad de egresados anualmente, sin embargo ninguno de éstos ha cumplido totalmente las recomendaciones de la agencia acreditadora APICE durante los últimos 10 años. Existen procedimientos frecuentes en la especialidad no incluidos en las recomendaciones.

ABSTRACT Introduction In Chile there are 4 universities with postgraduate programs in Otorhinolaryngology. The national organism that regulates postgraduate education in Medicine (APICE) recommends a minimal number of surgeries to be performed during the training, these suggestions were developed by a group of experts. Aim The objective of this paper is to explore the accomplishment of these minimal number of surgeries by the graduates of the Otorhinolaryngology Program from Universidad de Chile in the last 10 years. Material and method The surgical portafolio from the students graduated between 2006 and 2016 were reviewed. The following data was registered: year of completion of the program, surgery, kind of participation (surgeon or not), and academic location. Results In the period 77 physicians completed the program, eleven of them were excluded. The total analysis of 66 portafolios revealed that none of them accomplished a 100% of the minimal requirements suggested by APICE. Conclusions None of the graduates from the Otorhinolaryngology Program from Universidad de Chile in the last 10 years has fulfilled in 100% the requirements.

Declining Otolaryngology Resident Training Experience in Tracheostomies: Case Log Trends from 2005 to 2015.

Objective To evaluate recent tracheostomy surgical experience among otolaryngology residents and general surgery residents. Study Design Retrospective database review. Setting Accreditation Council for Graduate Medical Education otolaryngology and general surgery programs. Subjects and Methods Accreditation Council for Graduate Medical Education case log data from 2005 to 2015 for resident graduates in otolaryngology and general surgery were used to obtain mean graduate tracheostomy numbers, mean graduate composite case numbers, and number of graduating residents. Market share for each specialty was estimated through the derived metric of nationwide total tracheostomy graduate experience, calculated by multiplying the number of graduating residents by the mean number of graduate tracheostomies. Linear regression analysis was used to calculate trends. Multiple linear regression analysis was used for pairwise comparison of trends. Results From 2005 to 2015, mean graduate tracheostomy numbers for otolaryngology residents declined 2.3% per year, while those for general surgery residents increased 1.8% per year. Accounting for changes in number of resident graduates, market share of tracheostomy decreased 1.0% per year for otolaryngology and increased 3.0% per year for general surgery. Mean graduate composite case numbers increased significantly by 1.8% and 1.0% per year for otolaryngology and general surgery residents, respectively. Conclusion Tracheostomy case volume in otolaryngology residency has decreased steadily in comparison with general surgery residency. However, current otolaryngology graduates have more experience in tracheostomy when compared with general surgery graduates. While otolaryngology residents have excellent exposure to tracheostomy, otolaryngology programs should be made aware of this declining trend as well as changing procedural trends, which may affect training needs.

A New Instrument for Assessing Resident Competence in Surgical Clinic: The Ottawa Clinic Assessment Tool.

BACKGROUND: The shift toward competency-based medical education has created a demand for feasible workplace-based assessment tools. Perhaps, more important than competence to assess an individual patient is the ability to successfully manage a surgical clinic. Trainee performance in clinic is a critical component of learning to manage a surgical practice, yet no assessment tool currently exists to assess daily performance in outpatient clinics for surgery residents. The development of a competency-based assessment tool, the Ottawa Clinic Assessment Tool (OCAT), is described here to address this gap. STUDY DESIGN: A consensus group of experts was gathered to generate dimensions of performance reflective of a competent "generalist" surgeon in clinic. A 6-month pilot study of the OCAT was conducted in orthopedics, general surgery, and obstetrics and gynecology with quantitative and qualitative evidence of validity collected. In all, 2 subsequent feedback sessions and a survey for staff and residents evaluated the OCAT for clarity and utility. RESULTS: The OCAT is a 9-item tool, with a global assessment item and 2 short-answer questions. Among the 2 divisions, 44 staff surgeons completed 132 OCAT assessments of 79 residents. Psychometric data was collected as evidence of validity. Analysis of feedback indicated that the entrustability rating scale was useful for surgeons and residents and that the items could be correlated with individual competencies. CONCLUSIONS: Multiple sources of validity evidence collected in this study demonstrate that the OCAT can measure resident clinic competency in a valid and feasible manner.

Assessment of Surgical Competence: Development and Validation of Rating Scales Used for Laparoscopic Supracervical Hysterectomy.

OBJECTIVE: To develop a procedure-specific rating scale for laparoscopic supracervical hysterectomy (LSH), and to compare the construct validity and reliability with a general rating scale in laparoscopic surgery, global operative assessment of laparoscopic skills (GOALS). DESIGN: Prospective interobserver study. In collaboration with an expert group, we developed the procedure-specific rating scale, competence assessment tool for laparoscopic supracervical hysterectomy (CAT-LSH). LSH was performed by gynecologists with different levels of surgical competence levels (13 procedures were performed by inexperienced trainees, 13 by intermediate experienced, and 15 by laparoscopic experts). All procedures were video-recorded. Surgical performance was evaluated in all procedures using both CAT-LSH and GOALS by the surgical assistant, as well as by 2 blinded observers evaluating the video recordings. SETTING: University teaching hospital. PARTICIPANTS: Laparoscopic experts, consultants and gynecological registrars from the Department of Gynecology. RESULTS: There were significant differences between the 3 proficiency groups in both the rating scales. Mean GOALS score evaluated by the operating assistant and the 2 observers were for inexperienced surgeons 16.4 vs. 13.6 (p < 0.01), for surgeons with intermediate experienced 22.6 vs. 19.5 (p < 0.05) and for expert surgeons 26.1 vs. 22.4 (p < 0.01), respectively. Corresponding results for the CAT-LSH scores were 41.0/34.6 (p < 0.01), 49.2/43.1 (p < 0.01), and 58.7/51.1 (p < 0.01), respectively. The interrater reliability measured by the interclass correlation coefficient between the surgical assistant and the 2 blinded observers for GOALS and CAT-LSH were 0.71 and 0.75, respectively. CONCLUSIONS: The GOALS and CAT-LSH appear to have construct validity and high interrater reliability. Assessment of surgical competence during LSH is feasible in daily practice with objective rating scales like CAT-LSH and GOALS.

Early Implant Failures Related to Individual Surgeons: An Analysis Covering 11,074 Operations Performed during 28 Years.

BACKGROUND: Compared with knowledge on patient and implant component factors, little knowledge is available on surgeons' role in early implant failures. PURPOSE: To report incidence of early implant failures related to total number of operations performed by individual surgeons. MATERIALS AND METHODS: Early implant failures (≤1 year of implant prosthesis function) were reported after a total of 11,074 implant operations at one specialist clinic during 28 years of surgery. Altogether, 8,808 individual patients were treated by 23 different dentists, of whom 21 surgeons were specialists in oral surgery or periodontology. Recorded failures were related to total numbers of performed operations per surgeon, followed by statistical comparisons (χ2 ) between surgeons with regard to type of treated jaw and implant surface. RESULTS: Altogether, 616 operations were recorded with early implant failures (5.6%), most often observed in edentulous upper jaws after placing implants with a turned surface (p < .05). Significant differences between surgeons, gender of surgeon, type of treated jaws by the surgeon, and implant surface used by the surgeon could be observed (p < .05). CONCLUSIONS: Early implant failures are complex, multifactorial problems associated with many aspects in the surgical procedure. A stochastic variation of failures for individual surgeons could be observed over the years. Different levels of failure rate could be observed between the surgeons, occasionally reaching significant levels as a total or for different jaw situations (p < .05). The surgeons reduced their failure rates when using implants with moderately rough surfaces (p < .5), but the relationship of failure rate between the surgeons was maintained.

On orthopedic surgical skill prediction--the limited value of traditional testing.

OBJECTIVES: Primary: to assess the utility of our distal radius fracture repair model as a tool for examining residents' surgical skills. Secondary: to compare the residents' ability to achieve specific biomechanically measured fracture stability with traditional test scores. DESIGN: Our laboratory pioneered a model that measures biomechanical qualities of a repaired distal radius fracture. Before participation, all residents to be tested completed specified knowledge examinations. During the laboratory exercise, proctors observed each resident and completed Objective Structured Assessment of Technical Skills forms. At the completion of the laboratory, each specimen was tested biomechanically. Written examinations were completed in a proctored setting and computer examinations at home following the honor system. The laboratory exercise had adequate space and materials and allowed 60 minutes to complete the procedure. Residents had equal access to x-ray imaging. SETTING: The examination environment of the study resembled an operating room. PARTICIPANTS: Postgraduate years 3 and 4 orthopedic residents in our program were asked to participate. The institutional review board reviewed and approved the study as exempt. RESULTS: Fracture repair constructs capable of resisting loads expected during rehabilitation were created by approximately half the residents tested. However, traditional written and computer-based testing methods failed to predict which resident's fracture construct would pass the biomechanical testing. Prior in vivo similar case experience was not predictive. CONCLUSIONS: The idea that "book smart does not equal street smart" applies to the tested model. To measure surgical skill acquisition and increase public safety related to surgery, it will be necessary to employ new and specific examination methods that identify the skill to be acquired and test the acquisition of this skill as precisely as possible.

Attainment of surgical competence in otolaryngology training.

OBJECTIVES/HYPOTHESIS: Our aim was to determine the postgraduate year (PGY) of residency at which residents achieve competence in key otolaryngologic procedures as perceived by residents and program directors (PDs), determine resident or programmatic factors affecting PGY at which residents perceive attainment of competence, and evaluate the relationship between resident and PD perceptions for attainment of competence in these procedures. STUDY DESIGN: Cross-sectional survey. METHODS: We surveyed residents and PDs in US otolaryngology residencies in 2011 using SurveyMonkey.com and assessed subjective attainment of competence by residents for 32 otolaryngologic procedures. PGY at which subjective competence achieved per resident perception was determined using a logistic regression model; PD perception was determined by mean calculation. RESULTS: Two hundred seventy-seven residents (19.45%) and 39 PDs (37.86%) completed surveys. Residents achieved subjective competence later than expected by PDs for 25 of 32 procedures, although differences were generally small. The largest disparities were observed for nonsurgical office-based procedures, for which <90% of residents reported competence by PGY-5, whereas PDs expected competence before PGY-3. The greatest number of disparities was present in the subspecialty area of facial plastic and reconstructive surgery. Male gender predicted earlier self-reported attainment of competence in 10 of 32 procedures (P < .05). Degrees held, fellowship plans, and the size of the program were not significant predictors of PGY at which residents reported competence for most procedures. CONCLUSIONS: We provide baseline data on PGY at which residents and PDs feel competence is achieved in key otolaryngologic procedures. These results may guide milestone development for resident training and assessment. LEVEL OF EVIDENCE: NA.