87requiring integration of psychomotor, cognitive, and perceptual skill components
within the context of operative procedures with multiple steps and decision points
[ 56 – 58 ]. Problem: Technical skills have traditionally been the primary focus of sur-
gical training and performance assessments, for which the gold standard metrics
comprise procedure-specific checklists and global rating scales completed by expe-
rienced observers [ 33 , 59 ]. The emphasis on technical skills fails to appreciate the
importance of critical nontechnical aspects of surgical performance such as leader-
ship, teamwork, error recognition and management, and communication. While
there has been increasing emphasis on nontechnical skills, and development of mul-
tiple evaluation techniques, these skills are largely assessed in an isolated fashion
away from technical skills [ 55 , 60 – 66 ]. Moreover, while technical and nontechnical
skills metrics have shown validity and application to clinical care, there is still a lack
of appreciation for how these metrics relate to one another [ 62 , 63 , 67 , 68 ]. Solution:
As the concept of workplace-based assessment draws attention to assessing clinical
skills, they are actually used – in a complex, integrated fashion, a way to achieve the
goal of integrated and holistic assessments must be found [ 69 – 71 ].
Preliminary research using epistemic network analysis (ENA), a sophisticated
mathematical modeling technique, has shown promise in the ability to (1) integrate
performance metrics from a variety of data sources and (2) generate holistic assess-
ment models that reveal the complex interactions between performance metrics.
ENA has been used in multiple domains to model complex thinking and problem-
solving [ 72 ]. Recently, preliminary data analysis using ENA revealed significant
correlations between procedural outcomes (quality and errors) and how surgeons
talk during a simulated surgical procedure [ 73 – 75 ]. One of the most significant find-
ings of preliminary work using ENA is the discovery of a relationship between
procedural outcomes and how surgeons talk during a simulated surgical procedure
[ 73 – 75 ].
Conclusion
In a recent review of surgical assessment methods, 202 individual research
papers documented 567 different metrics of analysis; yet time was by far the
most prevalent, appearing in 69.8% of the reviewed material. [ 76 ] Task time can
correlate with objective skill, in some cases to near perfection [ 77 ]. However, the
peril with using a stopwatch to gauge surgical skill is immeasurable. How can
areas of improvement be identified without analysis of errors? In the same
review, laparoscopic and MIS were the most predominant skills setting and the
most frequently occurring skills cited overall. [ 76 ] Clearly this is a time where
the continued development and appraisal of MIS should foster a culture of incen-
tivized learning and analysis.
An estimated 48,000–90,000 people died in the year 2000 due to medical
errors [ 78 ]. How many of those deaths were due to errors because of poorly
earned or maintained MIS skill isn’t known or likely even calculable; however,
there are several recognizable truths. Surgical skill correlates to surgical out-
come, and training improves operating room performance [ 8 , 67 ]. The final key
is that training becomes more meaningful when used alongside an equally mean-5 Performance Assessment in Minimally Invasive Surgery