The feasibility of remote proctoring for the Fundamentals of Laparoscopic Surgery (FLS) Skills Test

Allan Okrainec, MD, Melina Vassiliou, MD, Andrew Kapoor, MSc, Kristen B Pitzul, MSc, Oscar Henao, MD, Pepa Kaneva, MSc, Timothy Jackson, MD, E. Matthew Ritter, MD

Toronto Western Hospital – University Health Network, Temerty/Chang Telesimulation Centre, Toronto, Ontario; McGill University Health Centre, Montreal, Quebec; Uniformed Services University, Bethesda, Maryland

INTRODUCTION: Fundamentals of Laparoscopic Surgery (FLS) certification currently requires that tests be administered at accredited test centers. Establishing and maintaining these test centers requires substantial investment of human and financial resources. In addition, test-takers may need to travel, which has both time and financial impacts. Previous studies have demonstrated that it may be possible to reliably score the FLS manual skills remotely using inexpensive web-based technologies such as videoconferencing. However, there have been no investigations examining the feasibility of administering and scoring the FLS exam remotely without the presence of an official onsite proctor. The objective of this study was to the assess the feasibility of remotely administering and scoring the FLS examination using live videoconferencing in comparison to standard onsite testing.

METHODS: Twenty participants of varying skill levels were tested at 2 accredited FLS testing centers – the University Health Network in Toronto and McGill University Health Centre in Montreal. Videoconferencing was set up at both sites using a telesimulation platform. An official FLS proctor administered and scored the FLS exam remotely while another on-site proctor scored the participants live. The remote proctor could monitor both the participants themselves in addition to an inside view of the FLS box using two videoconferencing connections. Onsite proctors were instructed only to intervene if necessary, and only if the remote proctor was not administering the exam as per protocol. The entire testing session was recorded at both institutions. Inter-rater reliability was compared using Intra class correlation coefficients (ICC) and modified grounded theory was used to identify themes for barriers to feasibility.

RESULTS: Mean total FLS score (+SD) for onsite proctors was 63.5 (22.76), and for remote proctors was 57.8 (25.23). There was a strong significant correlation between onsite and remote raters (ICC=0.995; p<0.0001). Similar correlations were observed for all five FLS tasks. Barriers to remote FLS test proctoring were classified into 3 distinct time points: (1) pre-task, (2) intra-task, and (3) post-task. Several challenges emerged during the FLS testing: (1) incorrect instrumentation and task setup (2) failure of internet connection, adjustment of camera view (3) failure to correctly present materials for scoring, and security of materials for scoring.

CONCLUSIONS: This study demonstrates that web-based remote proctoring of the FLS skills test is feasible with minor alterations to examination setup. Remote proctoring did not affect evaluation in comparison to onsite testing, although several barriers were identified. Further investigations are needed to determine solutions to these barriers, and whether they will impact the reliability and validity of the test. This study provides evidence for a potential alternative to address the high cost and human resource investment currently needed to administer FLS tests worldwide.


Session: Podium Presentation

Program Number: S108

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