Cataract Surgical Skill Assessment

Transcription

1 Cataract Surgical Skill Assessment Dear Editor: In the United States, the Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency training programs (including ophthalmology) teach and assess 6 general competencies (i.e., medical knowledge, communication and interpersonal skills, patient care, professionalism, practice-based learning, and systems-based practice). To fulfill the ACGME mandate ophthalmic residency programs need valid assessment tools to show that surgical competence has been achieved. We believe such assessment tools should be designed to teach as well as assess. Additionally, our experience around the world is that globally applicable teaching and assessment tools for surgical skill are desired but do not exist at present. Our objective is to develop a standardized, internationally valid tool to both teach and assess an ophthalmologist s competence in performing cataract surgery. Saleh et al 1 described an assessment tool called the Objective Structured Assessment of Cataract Surgical Skill (OSACSS). While clearly a good start, the scale could be improved by the addition of behavioral anchors and a rubric for evaluators. Also, there is no behaviorally or skill-based rubric for the evaluators to use when assessing the resident s competence. We started with the OSACSS s 20 steps and created a behaviorally anchored scoring rubric that exactly defines what is expected in each step. A group of content experts (the authors) worked together online via a Google Communication Site. A rubric draft was developed based on the Dreyfus model of skill acquisition (novice, advanced beginner, competent, proficient, and expert). The expert category was omitted because residents are not expected to become experts during training. Behavioral anchors were written by the authors and modified repeatedly until all authors were satisfied. A second group of 12 content experts from around the world then reviewed the draft and made suggestions. These experts teach cataract surgery in Argentina, Australia, China, Egypt, England, Germany, India, Nigeria, Peru, and the United States. Their suggestions were catalogued, reviewed by the authors and revisions made to produce the final draft (Figure 1, available at The International Council of Ophthalmology (ICO) has approved this assessment tool and thus we have labeled it the ICO-OSCAR:phaco. The specific behavioral narrative anchors in the rubric provide raters with objective benchmarks for comparative purposes and provides the learners with specific targets for behavioral change. However, phacoemulsification is not taught and is not the standard of care in all parts of the world. Thus, we modified our phacoemulsification assessment tool (Figure 1, available at by eliminating steps not relevant to extracapsular cataract extraction (ECCE) and adding steps relevant to ECCE. We then went through exactly the same process described previously to create behavioral anchors for the ECCE assessment tool s rubric (the ICO-OSCAR:ECCE) (Figure 2, available at In the United States, ophthalmology residency programs are required to show that in aggregate, residents in a program have performed a specified minimum number of cataract surgeries (quantity) and have an equivalent experience, but there are no standard requirements or measures to assess how well the resident did conducting the surgery (quality). Globally, much more variability exists. Indeed, many countries do not even require a minimum number of surgeries, let alone standards for competence. Cremers et al 2 developed the Objective Assessment of Skills in Intraocular Surgery, a 1-page objective evaluation form to assess residents skills in cataract surgery. The form is completed by an evaluator who directly observes the surgical procedure and includes objective data such as wound placement and size, phacoemulsification time, and total surgical time, etc. The same group developed a subjective rating of surgical skills named Global Rating Assessment of Skills in Intraocular Surgery. 3 This one-page form allows the evaluator to assign scores from 1-5 based on a behaviorally anchored rubric to domains such as preoperative knowledge, microscope use, instrument handling, and tissue treatment in addition to 7 other areas. Feldman and Geist 4 described the Subjective Phacoemulsification Skills Assessment as an evaluative instrument designed specifically for intraoperative assessment of resident phacoemulsification cataract extraction (PCE) surgery. This form delineates PCE into overall performance and specific steps of the procedure (e.g., capsulorrhexis, hydrodelineation, IOL implantation, etc). The ICO-OSCAR:phaco and ICO-OSCAR:ECCE provide the rater specific behavioral narrative anchors that are objective benchmarks for comparative purposes and provide the learner specific targets for behavioral change. It is hoped that these tools will offer a platform for standardization for teaching, training, and evaluation in this domain. Face and content validity have been established by incorporating comments from a group of content experts representing Australia, Africa, Asia, Europe, and North and South America. Further study is underway to show reliability of these assessment tools. KARL C. GOLNIK, MD Cincinnati, Ohio References HILARY BEAVER, MD Houston, Texas VINOD GAUBA, MRCOPHTH, PAMED Dubai, United Arab Emirates ANDREW G. LEE, MD Houston, Texas EDUARDO MAYORGA, MD Buenos Aires, Argentina GABRIELA PALIS, MD Buenos Aires, Argentina GEORGE M. SALEH, FRCS, FRCOPHTH Bedford, England 1. Saleh GM, Gauba V, Mitra A, et al. Objective structured assessment of cataract surgical skill. Arch Ophthalmol 2007;125: Cremers SL, Ciolino JB, Ferrufino-Ponce ZK, Henderson BA. Objective assessment of skills in intraocular surgery (OASIS). Ophthalmology 2005;112: Cremers SL, Lora AN, Ferrufino-Ponce ZK. Global rating assessment of skills in intraocular surgery. Ophthalmology 2005;112: Feldman BH, Geist CE. Assessing residents in phacoemulsification. Ophthalmology 2007;114:

2 Ophthalmology Volume 118, Number 2, February 2011 Figure 1. The International Council of Ophthalmology (ICO) has approved this assessment tool labeled the ICO-OSCAR:phaco. 427.e1

3 Figure 1. (Continued.) 427.e2

4 Ophthalmology Volume 118, Number 2, February 2011 Figure 1. (Continued.) 427.e3

5 Figure 2. The International Council of Ophthalmology (ICO)-OSCAR: extracapsular cataract extraction (ECCE). 427.e4

6 Ophthalmology Volume 118, Number 2, February 2011 Figure 2. (Continued.) 427.e5