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The Purpose of Operating Room Education
The two primary purposes of the education in the operating room are assessing cur-
rent surgical proficiency (knowledge, skill, judgment, professionalism) and facili-
tating continual advancement of this proficiency toward the ultimate goal of safe,
independent, competent surgical practice. Although a precise definition of “surgical
competence” may be difficult to articulate bringing to mind Justice Potter Stewart’s
description of obscenity, “I know it when I see it [ 7 ],” a reasonable working defini-
tion may be that upon graduation we would recommend our residents to friends and
family in need of medical care. It is important to have this framework in mind when
thinking about resident assessment and improvement. Evaluating how well a resi-
dent did, whether addressing a single operation, time spent on a particular rotation,
or their entire residency tenure, is not as important and extrapolating how well a
resident will do in their future independent practice. The decisions to allow residents
to progress at each step of their training and ultimately graduate are high-stakes
decisions and as such should not be made only on hunches and intuition.
Our patients understand this and the public demand for better accountability is
increasing. Historically most patients have placed tremendous trust in their physi-
cians and their training without looking for much to support their trust other than a
diploma on the wall. Public trust in physicians however has been declining, and
recently third-party groups such as Propublica [ 8 ] have been collecting and report-
ing available data on information such as surgical outcomes. Undoubtedly a similar
trend for increased public accountability of competence in medical and surgical
education will follow. For the sake of the public trust and our own conscience as
educators, we as teachers should be able to provide, “defensible, dependable, and
trustworthy operative performance information” [ 9 ] to support these high-stakes
decisions regarding our support of a trainee’s license to practice medicine. In the era
of evidence-based practice, medical decision-making relies on ample and accurate
data that has been collected and reported with clarity. Medical education decisions
should require similar stringent support.
Clearly it is impossible to have perfectly complete and accurate knowledge of a
resident’s operative competency or predict how he or she will perform in every pos-
sible scenario, but we should have as our goal when teaching in the operating room
an assessment system that provides a true picture of the resident’s competency tra-
jectory and can explain deviation from this trajectory due to factors such as changes
in operative environment or faculty variation. We must then also have the proper
training and knowledge to use the information we gain from this assessment to
guide our residents to be the best surgeons they can be.
Assessment of Operative Performance
Education in the operating room, in terms of both validation of competence and
guiding improvement, begins with a thorough and accurate assessment of surgical
skill. Both the quality of the individual evaluations and the total number of
M. Mirza and J.F. Koenig