Assessment of Performance During Advanced Laparoscopic Fellowship- A Single Subject Design

Iman Ghaderi, MD, MSc, Yoon Soo Park, PhD, Lauriane Auvergne, BBA, Timothy M Farrell, MD. University of North Carolina, Chapel Hill, NC.

INTRODUCTION: The objective of this study was to investigate the acquisition of advanced laparoscopic technical skills and to determine the association between continuous self-assessment of a trainee and that of an attending, using a single-subject design. Single subject designs are used widely in educational and behavioral research, where the subject serves as the control. The study was designed based on the “Practice-Based Learning and Improvement” ACGME competency that has been adopted by the Fellowship Council. Minimally invasive surgery fellows are required to use feedback from faculty and their own self-assessments to develop a plan for filling gaps in knowledge or skills.

METHODS AND PROCEDURES: This study collected yearlong consecutive assessments using valid technical assessment tools completed by a minimally invasive fellow (continuous self-assessments) and one faculty member at the University of North Carolina. Three commonly performed procedures in this fellowship included Heller myotomy (HM), paraesophageal hernia repair/ Nissen fundoplication (PEH/NF), and Roux-en-Y gastric bypass (RYGB). We used the Global Operative Assessment of Laparoscopic Skills (GOALS) and the Objective Structured Assessment of Technical Skills (OSATS) to assess general laparoscopic skills, and we used procedure-specific rating tools to assess performance during HM, PEH/NF, and creation of the jejunojejunostomy portion of the RYGB. In addition to descriptive statistics, a t-test and a linear mixed-effects regression were used to compare the ratings between assessors and measure changes in ratings throughout the year, accordingly. The scores for each assessment were averaged by month across assessors to determine incremental changes. Assessments with missing data and delayed completion were excluded, as were recurrent and revisional cases.

RESULTS: A total of 76 procedures (HM: n=16, PEH/NF: n=19, RYGB: n=41) were included (152 assessments by the fellow and the attending). The average ratings increased for each assessment every month by approximately 0.11 points (based on 5-point assessment tool scales), p<0.001, indicating a significant learning effect. The differences between baseline and 12-month ratings ranged between 1.00 and 1.57 points, depending on the procedure and assessment tool used. There were significant differences between ratings by trainee and faculty; ratings by faculty were significantly higher than the fellow’s self-assessments, indicating more stringent ratings by the fellow.

CONCLUSION: Our study demonstrates the feasibility of using objective assessment tools for assessment of performance during an advanced laparoscopic fellowship. These tools can be used as a quantitative index to monitor fellows’ learning curve and to provide objective feedback during self-directed learning to improve performance.

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