- Email: [email protected]
Should We Consider Testing for Skill in Surgery?
European Urology
European Urology 47 (2005) 480–481
Editorial
Should We ConsiderTesting for Skill in Surgery? Bertrand Guillonneau* Department of Urology, Memorial Sloan-Kettering Cancer Center, Sidney Kimmel Center for Prostate and Urologic Cancers, 1275 York Avenue, New York, NY 10021, USA Available online 9 February 2005
Every patient wants to know whether his surgeon is skilled, not to mention a ‘‘good surgeon’’. In this issue of the journal, the article by R. Katz et al. aims at providing a construct validity to the ability of a pelvic trainer to discern the differences in skill level of urologists in laparoscopic surgery based on their reported experience in this field.’’ Interestingly, the tests are not as sensitive as suggested and the authors are unable to differentiate someone without any experience from someone with minimal experience, a distinction at which tests should be particularly sensitive. And are occasional cholecystectomy or appendectomy really minimal experiences? The tests are not even sensitive enough to differentiate between ‘‘beginners’’ and basic surgeons for ligation passage and the 5-suture test, nor to differentiate between basic and advanced surgeons in the 5-suture test and the cutting circle test. What does this mean? It means that these tests merely measure the ability to take tests, with the same questionable reliability as IQ tests (which do not evaluate intelligence) or driving tests (which do not prevent people from having car accidents). The only conclusion that can be drawn from this study is that, assuming the students are honest, it shows what types of surgical experience students have had and what their experience consisted of. But beyond these tests, which are basically an entertaining quiz for fellows, we, the urologic community, should be aware of the dangers of such hidden normalization. This idea that everybody with a given score is similar and interchangeable—not because the tests are dangerous by themselves (IQ tests are useless as a measure of intelligence, everybody admits that) and therefore these kinds of surgical skill tests are * Tel. +1 646 422 4406; Fax: +1 212 988 0806. E-mail address: [email protected].
problematic because they open the door to a use that will escape us, sooner or later. If we accept the concept of an ‘‘objective’’ evaluation with tests, there is no doubt that eventually some other institutions will evaluate us, and not our peers. The questions raised by this article are deeply legitimate: How should we train? How should we evaluate? Together these mean: how should we teach? Over several centuries, European universities have built a system that has been duplicated everywhere: the basis for the quality of instruction is the teacher; the basis for the legitimacy of a student is the teaching he followed and the acknowledgement by his/her master. This system is the center of residency programs and the reason for the success and popularity of fellowship programs: the opportunity to spend the time needed to learn from a renowned teacher. Whathaschangedrecently,andperhapsappropriately, is that huge numbers of trainees want to rapidly learn a technique that requires time to master. Urologists have tried two remedies for this new problem: robotic assistance and time-limited hands-on sessions. Robotic assistance is one possible way to bypass the long and flat ‘‘learning curve.’’ The future will tell us if this is the way to reduce the teaching and training required. Personally, I do not think so; certain kinds of training, perhaps, but teaching and learning, definitively not. The second remedy is the development of ‘‘minifellowships,’’ ‘‘observerships,’’ ‘‘surgery schools,’’ and other labs and hands-on sessions. Everybody knows that these are not perfect ways to learn difficult techniques that require patience, time, and experience, but because all of these factors are lacking, there is a temptation to offer short training and to validate it with this kind of test. In effect, this test asks the trainee to take the whole responsibility for his teaching. It is certainly logical but not totally legitimate. In medicine there is a specific
0302-2838/$ – see front matter # 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2005.01.014
Editorial
relationship between student and teacher, and each should share the responsibility for the quality: the student by learning, the teacher by teaching. Moreover, we must remember that technical skill is not the goal in surgery; it is just the minimum we expect from a surgeon. Being a surgeon includes
481
different aspects, like medical knowledge and experience, of course, but also compassion and humanism. To train and teach surgery is not only an important responsibility but also an honor. No test will ever eliminate this responsibility, which we should claim.
European Urology 47 (2005) 480–481
Editorial
Should We ConsiderTesting for Skill in Surgery? Bertrand Guillonneau* Department of Urology, Memorial Sloan-Kettering Cancer Center, Sidney Kimmel Center for Prostate and Urologic Cancers, 1275 York Avenue, New York, NY 10021, USA Available online 9 February 2005
Every patient wants to know whether his surgeon is skilled, not to mention a ‘‘good surgeon’’. In this issue of the journal, the article by R. Katz et al. aims at providing a construct validity to the ability of a pelvic trainer to discern the differences in skill level of urologists in laparoscopic surgery based on their reported experience in this field.’’ Interestingly, the tests are not as sensitive as suggested and the authors are unable to differentiate someone without any experience from someone with minimal experience, a distinction at which tests should be particularly sensitive. And are occasional cholecystectomy or appendectomy really minimal experiences? The tests are not even sensitive enough to differentiate between ‘‘beginners’’ and basic surgeons for ligation passage and the 5-suture test, nor to differentiate between basic and advanced surgeons in the 5-suture test and the cutting circle test. What does this mean? It means that these tests merely measure the ability to take tests, with the same questionable reliability as IQ tests (which do not evaluate intelligence) or driving tests (which do not prevent people from having car accidents). The only conclusion that can be drawn from this study is that, assuming the students are honest, it shows what types of surgical experience students have had and what their experience consisted of. But beyond these tests, which are basically an entertaining quiz for fellows, we, the urologic community, should be aware of the dangers of such hidden normalization. This idea that everybody with a given score is similar and interchangeable—not because the tests are dangerous by themselves (IQ tests are useless as a measure of intelligence, everybody admits that) and therefore these kinds of surgical skill tests are * Tel. +1 646 422 4406; Fax: +1 212 988 0806. E-mail address: [email protected].
problematic because they open the door to a use that will escape us, sooner or later. If we accept the concept of an ‘‘objective’’ evaluation with tests, there is no doubt that eventually some other institutions will evaluate us, and not our peers. The questions raised by this article are deeply legitimate: How should we train? How should we evaluate? Together these mean: how should we teach? Over several centuries, European universities have built a system that has been duplicated everywhere: the basis for the quality of instruction is the teacher; the basis for the legitimacy of a student is the teaching he followed and the acknowledgement by his/her master. This system is the center of residency programs and the reason for the success and popularity of fellowship programs: the opportunity to spend the time needed to learn from a renowned teacher. Whathaschangedrecently,andperhapsappropriately, is that huge numbers of trainees want to rapidly learn a technique that requires time to master. Urologists have tried two remedies for this new problem: robotic assistance and time-limited hands-on sessions. Robotic assistance is one possible way to bypass the long and flat ‘‘learning curve.’’ The future will tell us if this is the way to reduce the teaching and training required. Personally, I do not think so; certain kinds of training, perhaps, but teaching and learning, definitively not. The second remedy is the development of ‘‘minifellowships,’’ ‘‘observerships,’’ ‘‘surgery schools,’’ and other labs and hands-on sessions. Everybody knows that these are not perfect ways to learn difficult techniques that require patience, time, and experience, but because all of these factors are lacking, there is a temptation to offer short training and to validate it with this kind of test. In effect, this test asks the trainee to take the whole responsibility for his teaching. It is certainly logical but not totally legitimate. In medicine there is a specific
0302-2838/$ – see front matter # 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2005.01.014
Editorial
relationship between student and teacher, and each should share the responsibility for the quality: the student by learning, the teacher by teaching. Moreover, we must remember that technical skill is not the goal in surgery; it is just the minimum we expect from a surgeon. Being a surgeon includes
481
different aspects, like medical knowledge and experience, of course, but also compassion and humanism. To train and teach surgery is not only an important responsibility but also an honor. No test will ever eliminate this responsibility, which we should claim.