The assessment of surgical competence

Dear Sir

Procedural skill forms a large component of surgical practice, and carries a significant influence on patient outcomes. The process of assessing the skill and competence is fraught with complications.

With the division of surgical training into ever-smaller segments and the impact of reduced working hours on clinical development, it is becoming important to divide each procedure into its constituent parts. This conforms to Peyton’s model for the teaching of practical skills and leads to faster and more effective education (Krautter et al. 2011), and as each component is “signed off” individually, a trainee can be safely assumed to be able to perform a procedure consisting of previously taught components.

Global rating in order to evaluate performance and competence at a specific procedure represents the alternative approach, with the philosophy being that each procedure is more than the mere sum of its parts. It does necessitate that each procedure be evaluated separately. One can argue that the most valuable assessment for a speciality trainee is whether they can safely and competently perform the procedures asked of them. As a summative assessment, it can be valued more than a detailed feedback process. The simplicity of the global rating and its inherent ease of use lend to it a universal appeal, resulting in continued use. The disadvantage is the reduced educational value; a trainee may know that they require further training, but not which area to focus on.

Procedural-based assessments [PBAs] have a clear advantage of breaking the procedure into the constituent parts and affording more detailed feedback to the trainee regarding their exact level. The application of PBAs to assessments allows a formative as well as a summative evaluation (Beard et al. 2009). Overcoming the taxing and time consuming workload of PBAs, as well as the volume of information can be achieved by a combination of an understanding trainer, who gives feedback in smaller more digestible portions, and through using the PBA in parts. Performing the entire PBA may not always be appropriate.

It is my opinion that these assessments can act to supplement each other, supplementing each other’s strengths and providing cross-cover to overcome weakness. The ideal may be to use PBAs with the addition of a global rating score to give an overall review point, enabling both trainer and trainee to have a handle on the assessment process.

Declaration of interest: The author reports no conflicts of interest.