Validity Evidence for the Fundamentals of Laparoscopic Surgery (FLS) program as an Assessment Tool: A Systematic Review

Benjamin Zendejas, MD, MSc, Raaj K Ruparel, MD, Juliane Bingener, MD, David A Cook, MD, MHPE. Mayo Clinic

Objective: The Fundamentals of Laparoscopic Surgery (FLS) uses five simulation stations (peg transfer, precision cutting, loop ligation, and suturing with extracorporeal and intracorporeal knot tying) to teach and assess laparoscopic surgery skills. We sought to summarize evidence regarding the validity of scores from the FLS assessment.

Methods: We systematically searched for studies evaluating the FLS as an assessment tool (last search update March 2013). We classified validity evidence using the currently standard validity framework (content, response process, internal structure, relations to other variables and consequences).

Results: From a pool of 11,628 studies, we identified 23 studies reporting validity evidence for FLS scores. Studies involved residents (n=19), practicing physicians (n=17), and medical students (n=8), in specialties of general (n=17), gynecologic (n=4), urologic (n=1), and veterinary (n=1) surgery. Evidence was most common in the form of relations with other variables (n=22, most often expert-novice differences). Only three studies reported internal structure evidence (inter-rater or interstation reliability), two studies reported content evidence (i.e., derivation of assessment elements) and three studies reported consequences evidence (definition of pass/fail thresholds). Evidence nearly always supported the validity of FLS total scores. However, the loop ligation task had limited discriminatory ability.

Conclusions: Validity evidence confirms expected relationships with other variables and acceptable inter-rater reliability, but other validity evidence is sparse. Given the high-stakes use of this assessment (required for board eligibility), additional validity evidence could better support the content (selection of tasks and scoring rubric) and consequences (favorable and unfavorable impact) of the FLS assessment.

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