Brief Commentary on the article “A Novel Clinical-Simulated Suture Education for Basic Surgical Skill: Suture on the Biological Tissue Fixed on Standardized Patient Evaluated with Objective Structured Assessment of Technical Skill (OSATS) Tools”

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A Novel Clinical-Simulated Suture Education for Basic Surgical Skill: Suture on the Biological Tissue Fixed on Standardized Patient Evaluated with Objective Structured Assessment of Technical Skill (OSATS) Tools

The Objective Structured Assessment of Technical Skill (OSATS) is a reliable and valid tool that has been increasingly used in skills training in medical education. The system uses a global rating approach to structure expert evaluation of technical skills, in which the experts work from a list of operative competencies which in turn are each rated on a scale anchored by behavioral descriptors. Compared to traditional surgical evaluations, OSATS is supposed to allow for less biased assessments of technical performance, and has demonstrated sufficient validity and reliability. Hence OSATS has been adopted broadly in general surgery, orthopedics as well as obstetrics and gynecology. One flipside that is attributed to OSATS is that OSATS might not objectively assess the quality of surgical results due to the predominantly observational nature of its scoring.

OSATS have been increasingly employed to assess the effectiveness of surgical skills training. Literature review shows that OSATS was employed to evaluate basic surgical skills training from as early as 1997 [1]. Recently, studies have been done where the researchers tried to create technical and non-technical standards for laparoscopic cholecystectomy by using the OSATS as well as OSANTS (Objective Structured Assessment of Non-Technical Skills) instruments [2]. Another study conducted in a low and middle income country setting looked at the effectiveness of simulation training in teaching procedural skills by using the OSATS instrument [3]. OSATS has also been employed to find whether training or natural talent is more significant in determining the surgical performance of laparoscopic operations. Based on OSATS, another study strived to provide subjective and objective assessments of simulation-based training among residents in hand-sewn vascular and bowel anastomosis [4]. Some studies have also compared a video recorded self-assessment of suturing and knot tying skills by novice trainees to the assessment by a senior attending surgeon by employing OSATS [5]. Studies have employed OSATS to look at venous dissection teaching for medical students using surgical pig models in medical schools.

Even in obstetrics, OSATS has been employed for skills evaluation. One study used OSATS in gynecology residents to study the ASC (Advanced Suturing Course (ASC) and it was found to improve open knot-tying skills [6]. Obstetrics and Gynecology residents at one institution were videotaped while performing a laparoscopic suturing and intra-corporeal knot-tying task at a surgical simulation workshop [7]. In this study, the authors designed an OSATS tool that includes a procedure-specific checklist (PSC) and global rating scale (GRS) to assess laparoscopic suturing and intra-corporeal knot-tying performance. Another study compared medical students’ skills for vaginal operative delivery by vacuum extraction (VE) after hands-on training versus video demonstration [8]. They randomized medical students to an expert demonstration or a hands-on training using a standardized VE algorithm on a pelvic training model and tested them with a 40-item OSATS scoring system to compare the results. In another study, the long-term effect of an educational workshop on the knowledge and ability of obstetrics and gynecology residents to repair fourth degree lacerations was assessed by employing the OSATS system [9].

In the current article, the authors have investigated the role of clinical simulation for basic suture training [10]. They divided the study group of medical students into three groups and put them into three stations: synthetic suture pad fixed on bench, synthetic suture pad fixed on standardized patient and porcine skin fixed on standardized patient. Then the subjects were asked to perform basic suturing techniques and were evaluated using OSATS. The students were provided a questionnaire after the examination also. Majority of subjects felt that the assessment was more objective when OSATS tool was used for evaluation.

Though simulation methods have been used widely for skills training in medical education, the current study reports a rather unique method in that they used a novel suture mould using biological skin(porcine skin) fixed on the standardized patient with a self-developed, patented tissue holder. Thus they were able to simulate a clinical environment for examination wherein communication was possible between the patient and the student during the procedure. Since OSATS requires examiners to be present outside the examination room, students are able to perceive this environment as being closer to real-world clinical setting rather than an examination setting. Also they used feedbacks from the students themselves about their experience during the simulation.

However, this study is not without its own drawbacks. The cohort design employed by the authors reduces the scope for statistical analysis. Also the rather small sample size mitigates the clinical significance of the study results. Nevertheless, the novelty of the study method throws open many possibilities for future studies in this field. Randomized controlled trials of a larger magnitude based on this idea can be carried out to validate the study results. A rather interesting thought is whether tissue-cultured human integument can be employed instead of porcine tissue for getting a better feel of human skin. Wider research is definitely warranted in this area to explore the possibilities further. To conclude, the use of OSATS for clinical simulation examination assessment can be recommended for wider adoption in medical curriculum.

DECLARATION OF INTEREST

No conflicts of interest. The authors alone are responsible for the content and writing of the paper.