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UK Surgical Trainees Assessed on Non-Technical Skills for the First Time

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23 Aug 2014

Whilst job assessments in many professions involve a rating for how well the person performs in a group, whether they communicate efficiently or display strong leadership qualities, it’s only the first time in the UK that similar skills are being formally evaluated in surgeons through the national curriculum, using a system devised by Britain’s largest and oldest surgical Royal College.

Non-Technical Skills for Surgeons or ‘NOTSS’ is the world’s only behavioural ratings system developed by and for surgeons. Created by the Royal College of Surgeons of Edinburgh (www.rcsed.ac.uk); which recently opened its first-ever base of operations in Birmingham to cater for the 80% of its UK membership based in England and Wales; the unique assessment system allows Britain’s trainees to be formally evaluated on abilities which have little to do with wielding a scalpel, yet everything to do with patient safety.

It’s known that three out of five (60%) adverse medical events involve surgical patients. Studies of behaviour in the operating room show that breakdowns in non-technical skills such as teamwork, leadership, communication, situation awareness, and poor decision-making are not uncommon and can lead to errors, poor outcomes including avoidable deaths, as well as higher compensation payouts.

Based on a model similar to those used in the aviation industry to test pilots’ cognitive skills, the NOTSS system was developed by a multidisciplinary steering group of surgeons, anaesthetists and the University of Aberdeen’s School of Psychology; and is designed to reduce the margins for human error.

Adoptedsince May this yearinto the Intercollegiate Surgical Curriculum Programme (www.iscp.ac.uk); which provides the approved UK syllabus for training in each of the ten surgical specialties; the NOTSS tool allows for structured assessment in:

  • Situation Awareness - gathering and understanding information
  • Decision Making - considering, selecting and communicating options
  • Leadership - Setting and maintaining standards, coping with pressure
  • Communication and Teamwork - Exchanging and coordinating information

“For many years now it’s been argued that avoidable deaths still occur because flawed learning behaviours and surgeons’ opinions of their own capabilities can lead to arrogance; also that training for future surgeons must encompass more than just clinical and technical skills. Other high-hazard sectors have recognised that technical expertise is not enough to ensure safety – for example airline pilots and anaesthetists have their own behaviour ratings systems (NOTECHS and ANTS, respectively) to assess performance. NOTSS is both innovative and unique in that it was developed entirely by surgeons for surgeons, underpinned by psychologists experienced in studying human factors.”

“There is increasing evidence that the contributory role of non- technical skills failures in surgical adverse events is higher than was ever recognised. Whilst most people are used to – and recognise the importance of – the concepts of IQ (intellectual quotient) v EQ or ‘emotional intelligence’; surgical training in the UK has only in recent years moved away from knowledge-based set pieces in favour of competency-based assessment in the workplace. This approach is encouraging greater emphasis on identifying the skills necessary to maximise safe and effective management of patients and requires an appreciation of the role of non-technical abilities, defined as the cognitive and interpersonal skills that underpin technical proficiency.

“NOTSS was designed primarily as an educational tool, to provide surgeons with a structure and with the language to observe, rate, and provide feedback on behaviours during routine cases. Whilst not designed specifically for quality control, there have been several emergent uses for it in this area. For example, surgeon-trainers have used NOTSS to deal with underperforming surgeons; to analyze surgical adverse events and to structure non-technical skills training – an adapted version has even been used recently in a pilot study by the Royal College of Obstetricians and Gynaecologists (RCOG) to evaluate competencies in the delivery suite.”

Surgeons have been using NOTSS in the OR and in simulated settings, and the RCSEd has been successfully running a NOTSS Masterclass for attending surgeons for several years. However, it is the first time now that it has been made available through the formal UK-wide surgical curriculum. Use of NOTSS has already spread to the US, Japan and Australia, where it has been adopted by the Royal Australasian College of Surgeons as part of their competence assessment and endorsed by the ACGME (Accreditation Council for General Medical Education).

According to President of the Royal College of Surgeons of Edinburgh Ian Ritchie, who is a consultant trauma and orthopaedic surgeon;

“Safety is an issue which concerns all those who care for patients and lies at the heart of medical practice. All surgeons have a primary responsibility to participate in established procedures and help develop new measures to improve patient safety: at The Royal College of Surgeons of Edinburgh we are committed to improving standards through education and training and by supporting research into human factors which may prevent or mitigate patient harm. We’re proud to have developed the world’s only behavioural marker tool for surgeons and are excited to see it adopted into the curriculum of all surgical specialties.”




About The Royal College of Surgeons of Edinburgh

RCSEd was first incorporated as the Barber Surgeons of Edinburgh in 1505, and is the oldest surgical corporation in the world with memberships approaching 25,000 professionals in over 100 countries worldwide. The College promotes the highest standards of surgical and dental practice through its interest in education, training and examinations, its liaison with external medical bodies and representation of the modern surgical and dental workforce. It is also home to the UK’s only Faculty of Surgical Trainers, open to all those with an interest in surgical training regardless of College affiliation. Find RCSEd on Twitter www.twitter.com/RCSEd and on Facebook www.facebook.com/rcsed

The College is based at Nicolson Street, Edinburgh, EH8 9DW and can be reached on (0)131 527 1600 or mail@rcsed.ac.uk. In March 2014, a new base opened in Birmingham, catering to the 80% of the College’s UK membership who are based in England and Wales.

For all media enquiries please contact the Communications Team on +447467 485145 or email comms@rcsed.ac.uk 


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