Objective surgical assessments for residents and experienced surgeons in the Yelp Era

Abstract

Low-cost surgical assessment tools such as the Objective Assessment of Skills in Intraocular Surgery (OASIS)1 and Global Rating Assessment of Skills in Intraocular Surgery (GRASIS)2 should be used in conjunction with valid risk profiles to help future and current eye surgeons prepare for future Yelp EraA competency assessments. A sincere thank you to Dr. Nandigam et al.3 on their important article on the cost effectiveness of 8 ophthalmology resident surgical training tools. We are honored the OASIS1 and GRASIS2 have helped residency programs. This publication incidentally coincides with recent media reports regarding public web sites evaluating surgeons publicly, claiming, “a surgeon who gets a 5-star rating…means the nonprofit is 97.5% sure the surgeon’s performance is better than the average United States surgeon.”B Thus on graduation, residents no longer will be evaluated privately by concerned mentors but will be publicly evaluated by insurances, public interest groups, and patients. Dr. David Hoyt, American College of Surgeons’ president, noted in The Washington Post the complexities of patients’ surgeries, stating that “rating a surgeon’s skill in performing a particular operation, without factoring in other considerations, leads to an incomplete analysis.”C While Dr. Hoyt is correct in these sites’ woefully inadequate analysis, insurance companies and public groups continue to demand full transparency on detailed complication rates. Such metrics, although, are meaningless without weighing metrics according to valid operative risk profiles with agreed-on benchmark for outcomes; higher vitreous-loss rates might mean experienced surgeons have higher risk patients. Thus, inexpensive tools (OASIS and GRASIS) can help our future surgeons prepare for the real world of “competency-assessments.” Ophthalmology leaders might consider creating a valid risk-assessment tool approved by residency program directors, the Association of University Professors of Ophthalmology, the American Society of Cataract and Refractive Surgery (ASCRS), the American Academy of Ophthalmology, and the American Board of Ophthalmology for all eye surgeries, such as we developed at Harvard Medical School for cataract surgeryD (Table 1; Supplement A, available at http://jcrsjournal.org), not only to fairly assess surgeons’ skills within our residencies and ophthalmic community’s perception, but also in the public’s. In addition, outcome benchmarks, weighted according to a total risk profile, should be established by eye surgeons and not public groups.Table 1: Risk Assessment in Cataract Surgery (RACS): A risk profile with face and content validity from 17 surgical experts at MEEI & Bascom Palmer.Table 1: Continued.In the interim, another benefit of the low-cost tools OASIS and GRASIS exists; that is, creating outcomes databases. We used OASIS and GRASIS to create a large database at Harvard Medical School/Massachusetts Eye and Ear Infirmary (MEEI) to analyze all cases on the cataract service. This database allowed us to use data to improve residents’ and patients’ surgical outcomes. We presented our first use of our OASIS database at the ASCRS meeting in 2004.E We calculated a 45% decrease in resident vitreous loss rates when residents operated with preceptors who attended more than 100 resident cases per year versus preceptors who attended fewer than 100 resident cases per year. This supported a departmental decision to use only full-time attending staff as surgical preceptors, showing the power of the low-cost OASIS to improve outcomes. Similarly, Shen et al.4 recently published their use of GRASIS at MEEI’s Glaucoma Service to show residents’ training improvements by changing the glaucoma rotation structure. In addition, the OASIS database helps calculate resident cystoid macular edema rates5 and the incidence of 1-day postoperative pressure spikes6 and showed lower surgical complication rates in left-handed residents.7 Every residency program could benefit from an OASIS database to help individual residents/programs self-regulate their surgical curriculum. Such information could help program directors develop national benchmarks for best practices/outcomes for each stage of residents’ surgical training. The OASIS and subjective tools (GRASIS and Global Assessment of Skills in Plastic Surgery of the EyeF) help provide detailed feedback to individual residents and establish benchmarks versus saying a resident surgeon is “good” or “bad.” Electronic medical records should facilitate a self-populating database for this purpose. Using these tools in private practice could also help surgeons self-monitor/self-regulate without external forces determining surgical competence. If not, insurance panels could begin to publish surgeons’ vitreous loss rate without noting preoperative risk profiles and ultimately determine a surgeon’s retirement. We hope to see the day where eye surgeons create fair risk-adjusted benchmarks on outcome measures for all eye surgeries before public interest groups blindly determine best outcomes for us and our patients.