Assessing residents in phacoemulsification.

Dear Editor: Since the American Board of Ophthalmology introduced surgical skills as a seventh competency to complement the 6 core competencies of residency education as endorsed by the Accreditation Council for Graduate Medical Education, there has been a push to create explicit methods to assess resident surgical performance. Here we describe the results of a reliability study of the Subjective Phacoemulsification Skills Assessment (SPESA), an evaluative instrument designed specifically for intraoperative assessment of resident phacoemulsification cataract extraction (PCE) surgery (Fig 1 [all figures and tables available at http://aaojournal.org]). We developed the SPESA to more completely assess resident performance in PCE surgery, the surgical technique most emphasized in ophthalmology training. Previously described assessment tools—such as OASIS (Objective Assessment of Skills in Intraocular Surgery), an in-depth record of preoperative, intraoperative, and postoperative data; GRASIS (Global Rating Assessment of Skills in Intraocular Surgery); and ESSAT (Eye Surgical Skills Assessment Test)—address many aspects of resident surgical performance but fail to assess the critical components of PCE surgery. Our assessment tool meets this challenge by combining a global approach, similar to that employed in GRASIS and ESSAT, with detailed stage-specific criteria. SPESA was developed under the guidance of 4 attending ophthalmologists who regularly perform and teach PCE surgery at George Washington University. The instrument contains 15 qualitative descriptions of ideal performance of PCE surgery. Evaluators judge resident performance by circling their level of agreement with each description. There are 6 measures of overall performance (respect for tissue, equipment handling, microscope use, use of both hands, knowledge of equipment, and time and flow of operation) and 9 measures of the stages of operation (incision, capsulotomy, hydrodissection, hydrodelineation, phacoemulsification, irrigation/aspiration, IOL placement, wound closure, and complications). Sixty ophthalmology faculty members from residency programs across the nation were invited by e-mail to assess a single digitally recorded PCE surgery performed by an anonymous second-year resident. The participants remained blinded to the resident’s level of training. Participants reviewed the SPESA form, watched the resident PCE surgery, and then completed the evaluation of the resident’s performance. Fourteen faculty members from 9 different ophthalmology programs participated in the study between October 2005 and February 2006. Twelve of the total 15 criteria were included in the study. Knowledge of equipment, hydrodelineation, and complications were not included because there was not enough audio information to evaluate the former, and the latter two were not applicable to the case.