Resident Performance Assessment: A Crucial Area for Development

Abstract

Plastic surgery resident assessment has become the next element in resident education that must be developed. Reliable, comprehensive resident evaluation is currently difficult to achieve because of inconsistent assessor participation and an incomplete assessment toolbox. Recent advances in technology may be able to help, but they require judicious application. In particular, attention should be paid to assessing all levels of competence. Miller’s pyramid of assessment can help guide the process.1 The foundation of the pyramid is assessment of what a resident “knows.” Multiple choice or short answer examinations are a familiar tool that evaluates a resident’s medical knowledge. Smart phone applications and the online Plastic Surgery Education Network are an improvement over the older paper exams in which they provide both content and continuous assessment of knowledge and immediate feedback. Residents are able to test themselves at their own pace whereas teachers can monitor their progress and provide tailored education based on demonstrated need. The next level up on the pyramid is assessing what a resident “knows how” to do. Oral examinations do a good job of eliciting a plastic surgery resident’s knowledge of how to deliver good patient care or operate. The cognitive aspects of surgery can also be tested by computer simulators, drawing, and scripting. A resident’s ability to draw a procedure correlates well with the ability to perform the procedure. A resident’s operative script gives insight into the ability to plan and adapt, and the script serves as a permanent technical manual for the resident to revise over the course of a career. Overall, plastic surgery has adequate tools to assess the first 2 levels of the pyramid. The challenge lies in assessing the next 2 levels, particularly in the operating room. The third level of the assessment pyramid has the resident “show how.” In the clinic, standardized patients or simulated scenarios provide a safe way of allowing a resident to demonstrate a required competence before engaging with a real patient. For the operating room, surgical skills labs with cadavers or animal models and both low and high fidelity surgical simulators are excellent assessment tools. Particularly important is the ability of these tools to both teach and provide meaningful feedback in a way that does not put a patient at risk. The top of Miller’s pyramid is “does,” assessing a resident treating a real patient in the clinic or operating room. Portable sport cameras, stationary video cameras, and in-line recording of microsurgery allow direct, valid assessment of a resident’s ability to manage a patient or perform a surgical technique when filtered through the Objective Structured Clinical Examination or Objective Structured Assessment of Technical Skills rubrics available on the American Council for Graduate Medical Education website. Smart phone applications that allow for immediate intake and recording of an operative assessment can increase assessor participation, but in the end, technology cannot eliminate the need for an experienced surgeon to be the ultimate resident assessor.