Remote FLS Testing: Ready for Prime Time

Allan Okrainec, MD2, Melina Vassiliou, MD1, M. Carolina Jimenez, MD2, Oscar Henao, MD2, Pepa Kaneva, MSc1, Matthew Ritter, MD3. 2Toronto Western Hospital – University Health Network, Temerty/Chang Telesimulation Centre, Toronto, 1Montreal General Hospital, McGill University, Montreal, Canada, 3Uniformed Services University, Bethesda, Maryland

Introduction: The Fundamentals of Laparoscopic Surgery (FLS) program has gained widespread acceptance throughout the world and is considered by many to be the gold standard for teaching and assessing laparoscopic skills. In order to become FLS certified, candidates must take the FLS exam at one of the 73 approved FLS regional testing centres across the United States and Canada, or at an FLS course offered at certain surgical conferences. Maintaining these test centres requires considerable investment in human and financial resources by SAGES. Additionally, it can be challenging for individuals outside North America to become FLS certified, with significant time and travel required. Preliminary work suggests that it may be possible to reliably score the FLS manual skills component remotely using videoconferencing software and equipment. Further work is needed, however, to ensure that testing protocols and procedures can be maintained according to defined testing standards established by SAGES, emphasizing the importance of test integrity and security.

Objective: The purpose of this study was to validate the integrity and validity of the FLS manual skills exam administered remotely in a real-world environment according to standard FLS testing protocols.

Methods: Two rooms were set up and connected via Skype using a previously described telesimulation configuration (Image 1). The test taker presented to the FLS testing room and was greeted by an invigilator who established the Skype connection. The remote proctor (RP) registered the test taker, directed the entire exam and scored the test. An onsite proctor (OP) was present as a control to silently score the exam and identify any critical errors. Testing materials were always kept within the field of view of the remote proctor. Each participant completed a pre- and a post-test questionnaire. Interrater reliabilities of onsite and remote FLS scoring data were compared using intraclass correlation coefficients (ICCs).

Results: Twenty participants took the FLS manual skills exam including 10 residents, 5 medical students, 3 fellows, and 2 attending surgeons. There was excellent interrater reliability between total FLS scores of the remote and onsite proctors (ICC 1.00, CI [1.00 – 1.00]). No critical errors were identified by the onsite proctor which would have affected the FLS score. Four testing sessions experienced a dropped Skype connection that needed to be restarted. In the post-test questionnaire, 80% of participants indicated an excellent or good experience with the remote testing experience. 90% thought that the results reported by the remote proctor would be accurate. All participants who had previous experience with the FLS test considered that standard in person and remote testing were comparable.

Conclusion: This study demonstrates that a remote proctor is able to administer the FLS manual skills exam reliably, securely, and according to FLS standards. With a consistent increase in the number of individuals around the world seeking FLS certification, remote proctoring could become a strategy to increase access to FLS certification while containing costs. Remote proctoring could also be considered as a way of maintaining quality standards at current FLS test centers.

Image 1 - Study setup

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