A pilot study to assess the construct and face validity of the Northwestern Objective Microanastomosis Assessment Tool

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OBJECT

Microsurgical skills remain an integral component of neurosurgical education. There is a need for an objective scale to assess microsurgical skills. The objective of this study was to assess the face and construct validity of a benchtraining microanastomosis module and an objective assessment scale, i.e., the Northwestern Objective Microanastomosis Assessment Tool (NOMAT).

METHODS

Medical students, neurosurgical residents, and postdoctoral research fellows at Northwestern University were enrolled in the study. Trainees were divided into 3 groups based on microsurgical experience: 1) experienced, 2) exposed, and 3) novices. Each trainee completed two end-to-end microanastomoses using a 1-mm and a 3-mm synthetic vessel. Two cameras were installed to capture procedural footage. One neurosurgeon blindly graded the performance of trainees using both objective and subjective methods to assess construct validity. Two neurosurgeons reviewed the contents of the simulation module to assess face validity.

RESULTS

Twenty-one trainees participated in the study, including 6 experienced, 6 exposed, and 9 novices. The mean NOMAT score for experienced trainees on the 1-mm module was 47.3/70 compared with 26.0/70 and 25.8/70 for exposed and novice trainees, respectively (p = 0.02). Using subjective grading, experienced trainees performed significantly better on the 1-mm module (64.2/100) compared with exposed or novice trainees (23.3/100 and 25.0/100, respectively; p = 0.02). No statistical difference between groups was noted for the 3-mm module with both NOMAT and subjective grading. Experienced trainees took less time to perform both tasks compared with the others.

CONCLUSIONS

Face and construct validities of the microanastomosis module were established. The scale and the microanastomosis module could help assess the microsurgical skills of neurosurgical trainees and serve as a basis for the creation of a microsurgical curriculum.

ABBREVIATIONSNOMAT = Northwestern Objective Microanastomosis Assessment Tool; OSATS = Objective Structured Assessment of Technical Skill.

OBJECT

Microsurgical skills remain an integral component of neurosurgical education. There is a need for an objective scale to assess microsurgical skills. The objective of this study was to assess the face and construct validity of a benchtraining microanastomosis module and an objective assessment scale, i.e., the Northwestern Objective Microanastomosis Assessment Tool (NOMAT).

METHODS

Medical students, neurosurgical residents, and postdoctoral research fellows at Northwestern University were enrolled in the study. Trainees were divided into 3 groups based on microsurgical experience: 1) experienced, 2) exposed, and 3) novices. Each trainee completed two end-to-end microanastomoses using a 1-mm and a 3-mm synthetic vessel. Two cameras were installed to capture procedural footage. One neurosurgeon blindly graded the performance of trainees using both objective and subjective methods to assess construct validity. Two neurosurgeons reviewed the contents of the simulation module to assess face validity.

RESULTS

Twenty-one trainees participated in the study, including 6 experienced, 6 exposed, and 9 novices. The mean NOMAT score for experienced trainees on the 1-mm module was 47.3/70 compared with 26.0/70 and 25.8/70 for exposed and novice trainees, respectively (p = 0.02). Using subjective grading, experienced trainees performed significantly better on the 1-mm module (64.2/100) compared with exposed or novice trainees (23.3/100 and 25.0/100, respectively; p = 0.02). No statistical difference between groups was noted for the 3-mm module with both NOMAT and subjective grading. Experienced trainees took less time to perform both tasks compared with the others.

CONCLUSIONS

Face and construct validities of the microanastomosis module were established. The scale and the microanastomosis module could help assess the microsurgical skills of neurosurgical trainees and serve as a basis for the creation of a microsurgical curriculum.

Simulation is increasingly recognized as an important tool to enhance surgical education.19,30,33,37 While simulation has become a cornerstone in skill training and assessment in many areas of health care, incorporation into neurosurgical curricula has lagged.17 The complexities of neurosurgical procedures, financial and time constraints of the field, as well as the absence of validated assessment tools and curricula have contributed to this delay in progress.2,10,11,17 Microsurgery remains an integral component of neurosurgical education and achieving proficiency in this area is critically important to neurosurgical trainees.11 While the nature of the microsurgical procedures varies between subspecialties such as spine, skull base, vascular, and peripheral nerve, end-to-end microanastomosis of small-caliber vessels can be considered as a prototype procedure for the acquisition of microsurgical skills because it incorporates the basic concepts and fine motor skills necessary across subspecialty areas.24,37 Enhanced proficiency with microanastomosis procedures has been shown to translate into improved general microsurgical skills.5 Based on this concept, we developed a microanastomosis model and a corresponding assessment tool that would allow us to rate the microsurgical skill of neurosurgical residents and could potentially be used to track their progress and their learning curves. The aim of this study was to establish two important types of validity related to our module: 1) face validity, by examining the faithfulness of the module in replicating a real-world microsurgical setting; and 2) construct validity, by examining the ability and sensitivity of the module to assess the microsurgical performance of trainees with different levels of experience.

Methods

Microanastomosis Module

A bench module for the assessment and enhancement of resident microsurgical skills was developed in the Department of Neurological Surgery at Northwestern University's Feinberg School of Medicine. The module consists of performing one 1-mm and one 3-mm vessel end-to-end microanastomosis using a surgical microscope, a microsurgical kit, and 8-0 and 10-0 nylon microsurgical sutures (Fig. 1A and B). An objective assessment scale—the Northwestern Objective Microanastomosis Assessment Tool (NOMAT)—was developed to assess the operator's performance (Appendix 1). The NOMAT scale is a 14-item Likert-type assessment tool derived from the Objective Structured Assessment of Technical Skill (OSATS).15,27 The items in the NOMAT involve surgical metrics that were carefully selected and defined by 2 experienced vascular neurosurgeons (B.R.B. and H.H.B.) and a postdoctoral research fellow (S.G.A.). These metrics take into account important technical nuances required to successfully perform a surgical microanastomosis. Operator positioning and posture are also assessed using the NOMAT scale as they may affect the ease of motion and the precision of surgical maneuvers. The importance of optimizing positioning and posture has been strongly emphasized in fields requiring eye and hand coordination such as music and sports, where good positioning and posture have been shown to correlate with better technical performance and outcome.20,39 Our scale also attempts to assess microsurgical skills directly related to the microanastomosis itself including handling of the needle and surgical instruments, manipulation and respect of vascular tissue, insertion of the sutures and knot tying, and finally, the quality of the anastomotic line off and on the pump (Fig. 1C).

FIG. 1.
FIG. 1.

A: Photograph of the microanastomosis laboratory, including the surgical microscope, operative desk, camera, and video recording setup. B: Photograph of the microsurgical kit. C: Photograph of the petri dish, red dye, and fluid pump. Figure is available in color online only.

Study Design

Institutional Review Board approval was obtained at Northwestern University to allow neurosurgical trainees, postdoctoral research fellows, and medical students to be filmed while performing the 1- and 3-mm surgical microanastomoses. Two important types of validity were assessed in this study: face validity and construct validity. By definition, validity can be described as “the property of being true, correct and in conformity with reality.”16 When evaluating an assessment tool, validity can be defined as the ability of the tool to accurately measure the event or quantity it is supposed to measure.16,37 Face validity evaluates the content of a surgical simulation module, including the fidelity of the entire surgical setting and the realism of the surgical equipment and materials used.16,37 To assess face validity, 2 experienced vascular neurosurgeons (B.R.B. and H.H.B.) at our institution reviewed and approved the contents of our simulation module.

Construct validity, on the other hand, is defined as “the ability of an assessment tool to differentiate between experts and novices performing a given task.”16 Naturally, experts should perform better than novices on a given surgical task due to their previous surgical experience. Therefore, a proper assessment tool should clearly demonstrate this difference to be deemed suitable for the evaluation of surgical performance. To study construct validity, the trainees were divided into 3 groups according to their general experience with microsurgery: 1) the experienced group included residents in postgraduate years 6 and 7 who had been exposed to various types of microsurgical techniques in the operating room, and postdoctoral research fellows who underwent long periods of deliberate practice (> 50 hours) performing the microanastomosis; 2) the exposed group included intermediately trained residents in postgraduate years 3–5, who had received some microsurgical training in the operating room; and 3) the novices group included residents in postgraduate years 1 and 2, as well as medical students, who had no previous experience with microsurgery.

Each trainee performed an end-to-end microvascular anastomosis on one 1-mm and one 3-mm artificial vessel. None of the trainees received any orientation prior to or during the procedures. Only minor assistance was offered, when needed, in the form of adjusting the surgical stool or the surgical microscope (position or focus). A postdoctoral research fellow prepared the vessel (Kezlex, Ono & Co., Ltd.) in an identical fashion prior to each procedure. The vessels were placed on a clean petri dish, hydrated, and approximated to facilitate suturing. Two cameras were installed in the laboratory to capture procedural footage: 1) Camera 1 captured operator positioning and posture without showing the patient's head, and 2) Camera 2 recorded events occurring in the operative field under the surgical microscope (Fig. 2). All the participants were dressed in surgical gowns and gloves to ensure de-identification to the rater. Video files from both cameras were de-identified and then encoded and stored on a secure hard drive. An identification spreadsheet was created to help correlate the scores to their corresponding operators for subsequent data analysis. Another encoded spreadsheet was created to document the task time (duration) of each procedure. The task time was standardized for all procedures starting at the moment of insertion of the needle through the vessel wall and ending at the time of anastomosis completion. After completion of each anastomosis (1 mm or 3 mm), a postdoctoral research fellow used an infusion pump to inject red dye into the vessel and record any vascular injury or anastomotic leak. The vessel was then opened axially to assess and rate the anastomotic line. The method used to assess the anastomotic line is illustrated in Video 1.

Video 1. Clip showing an example of a “good” microsurgical performance. The method used to assess the anastomotic line is shown. Copyright Bernard R. Bendok. Published with permission. Click here to view with Media Player. Click here to view with Quicktime.

FIG. 2.
FIG. 2.

Camera 1 capturing de-identified operator positioning and posture (inset) and Camera 2 capturing the operative field under the surgical microscope. Figure is available in color online only.

An expert vascular neurosurgeon (B.R.B.) blindly graded the performance of the participants using both an objective method (NOMAT; maximum score = 70) and a subjective method that relied on the overall performance of the operator and on whether the rater believed the microanastomosis would be viable in vivo (maximum score = 100). The rater was completely blinded to the operator's identity. After the rating process was completed, the results were integrated into 1 spreadsheet for data analysis.

Statistical Analysis

The Kruskal-Wallis test was used to analyze statistical differences between the NOMAT scores and the subjective scores of the 3 groups of participants. Variability rates among experience levels were compared using Cochran-Armitage trend tests. Statistical significance was considered when p was < 0.05.

Results

NOMAT Grading

Twenty-one trainees with variable levels of microsurgical experience participated in the study. The trainees were divided into 3 categories of microsurgical experience: experienced (n = 6), exposed (n = 6), and novice (n = 9). The results of both the NOMAT and the subjective scoring are shown in Table 1. Scores obtained from the NOMAT and the subjective grading system correlated well with the level of experience of the trainees. This correlation was particularly obvious when performing the 1-mm vessel microanastomosis that requires greater microsurgical dexterity compared with that needed to perform a 3-mm vessel microanastomosis. The mean NOMAT score for experienced trainees performing the 1-mm microanastomosis was 47.3/70 compared with 26.0/70 and 25.8/70 for exposed and novice trainees, respectively (p = 0.02; Table 1). No statistically significant difference between groups was noted for the 3-mm microanastomosis: the mean NOMAT score of the experienced group was 47.8/70 compared with 45.0/70 and 39.6/70 for exposed and novices, respectively (p = 0.53; Table 1). Postdoctoral research fellows, who underwent extensive training on the module, obtained higher average NOMAT scores compared with other experienced trainees (58.0/70 vs 42.0/70 on the 1-mm microanastomosis and 63.0/70 vs 40.3/70 on the 3-mm microanastomosis, respectively). Examples of both “good” and “poor” performances are shown in Videos 1 and 2, respectively.

Video 2. Clip showing an example of a “bad” microsurgical performance. Copyright Bernard R. Bendok. Published with permission. Click here to view with Media Player. Click here to view with Quicktime.

TABLE 1

Results of the NOMAT, subjective grade, and in vivo viability ratings of the 1- and 3-mm microanastomoses in each group

Microanastomosis*Experienced (n = 6)Exposed (n = 6)Novice (n = 9)p Value
1-mm vessel
 Mean NOMAT (range)47.3 (20–64)26.0 (17–40)25.8 (16–36)0.02
 Mean subjective grade (range)64.2 (25–85)23.3 (10–40)25.0 (0–60)0.02
 In vivo viability5 pass, 1 fail0 pass, 6 fail1 pass, 8 fail< 0.01
 Mean task time in min (range)19.5 (12.0–32.9)29.2 (13.6–40.2)53.6 (20.9–88.4)Not applicable
3-mm vessel
 Mean NOMAT (range)47.8 (33–66)45.0 (31–63)39.6 (25–50)0.53
 Mean subjective grade (range)58.3 (30–95)55.0 (35–85)38.3 (10–65)0.29
 In vivo viability2 pass, 4 fail3 pass, 3 fail3 pass, 6 fail0.94
 Mean task time in min (range)27.8 (13.3–53.4)35.5 (22.3–48.0)69.0 (32.0–113.8)Not applicable

Score ranges for each of the 3 tests were as follows: NOMAT (0–70), subjective grade (0–100), and in vivo viability (pass/fail).

Subjective Grading

Subjective grading was included in this study because it is a commonly used means to provide feedback to surgical trainees after each procedure. In our study, experienced trainees performed significantly better on the 1-mm microanastomosis (64.2/100) compared with exposed or novice trainees (23.3/100 and 25.0/100, respectively, p = 0.02; Table 1). This significant difference, however, was not found in the 3-mm vessel microanastomosis (p = 0.29; Table 1). The end product of the 1-mm microanastomosis was determined by the rater to be “viable in vivo” in 5 of 6 microanastomoses performed by experienced trainees. All other trainees, except for 1 novice, failed to achieve a “viable” end product at the end of the procedure (p < 0.01). On the other hand, 2 of 6 experienced trainees, 3 of 6 exposed trainees, and 3 of 9 novices were able to achieve a “viable” 3-mm microanastomosis at the end of the procedure (p = 0.94).

Task Time

Surgical task time can be a reflection of surgical skill, and thus was incorporated as a variable in our assessment of technical proficiency. Experienced trainees took much less time to perform both tasks compared with more junior trainees. The mean task time to perform a 1-mm microanastomosis was 19.5 minutes for those with experience compared with 29.2 minutes for those with some exposure to microsurgery and 53.6 minutes for novices. The mean task time to perform a 3-mm microanastomosis was 27.8 minutes for those with experience compared with 35.5 minutes and 69.0 minutes for exposed trainees and novices, respectively.

Face Validity

The face validity of our simulation module was defined by input from 2 experienced vascular neurosurgeons (B.R.B. and H.H.B.) who assessed the fidelity of the surgical setting, the microsurgical instruments, and the synthetic vessels. Both neurosurgeons agreed upon the suitability and coherence of the grading scale in assessing microsurgical skill.

Discussion

Simulation represents a unique opportunity for neurosurgical trainees to acquire and refine their skills in a safe and stress-free environment.10,11,13,34,38 According to the Dreyfus model of skill acquisition, the road to achieving mastery involves 5 stages of increasing skill: 1) novice, 2) advanced beginner, 3) competent, 4) proficient, and 5) expert.8 The main challenge to applying this model in neurosurgical education is that despite the presence of several simulation models, there are currently no validated tools to objectively assess and follow the progress of an operator's skill level.4,6,7,25,26,31,35,36 The NOMAT scale was developed to provide neurosurgical trainees with objective means of assessing their microsurgical performance at baseline, and further allow them to track their progress and their learning curves.

Our simulation module was developed based on a thorough review of the literature with an emphasis on validation and based on the surgical experience of our departmental vascular neurosurgeons.3,21,23,30,37,40 We used a synthetic vessel model (Kezlex) to perform the microanastomoses because it was deemed to be more cost-effective, more readily available, and easier to handle, store, and maintain compared with both animal and virtual computerized models.18,28 We selected the surgical metrics of the NOMAT scale based on previously published literature, expert surgical opinion, and the OSATS scale, which was previously validated for general surgery procedures.15,27 The NOMAT scale involves technical steps and subskills that are believed to be essential to successfully performing a microsurgical anastomosis. It covers general microsurgical principles such as operator positioning and surgical microscope handling, as well as other technical aspects related to the microanastomosis itself, such as needle handling, knot-tying efficiency, spacing of sutures, and the appearance and functionality of the end anastomotic product. Using these metrics, neurosurgical trainees can repeatedly evaluate their performance at each microsurgical step, track their progress, and with adequate supervision eventually become proficient at complex microsurgical tasks.22 Our microanastomosis module was integrated into the simulation-based neurosurgical training course that was held at the 2012 Congress of Neurosurgical Surgeons annual meeting. Data obtained from the course showed that the module could be used to assess and track the technical proficiency of neurosurgical residents when performing a microsurgical anastomosis before and after receiving proper guidance and supervision.9 This course showed the feasibility of using the NOMAT scale in a diverse group of neurosurgical trainees of various skill levels. It was shown to be easy to use and capable of tracking the progress of operators as they learn from their seniors and refine their motor and cognitive skills.

The principles of validating simulators and objective assessment scales are well established in the literature.16 For a simulation module to be considered valid, it should ideally be assessed for face, content, construct, concurrent, and predictive validity, as well as inter- and intrarater reliability.16,23 The data from the current study support the construct validity of the microanastomosis module and the corresponding assessment scale because the scale was able to differentiate between experienced and nonexperienced trainees, particularly with the 1-mm vessel microanastomosis (p = 0.02). This observation could be explained by the fact that the 1-mm procedure is more technically demanding compared with the 3-mm procedure and is therefore more sensitive at detecting differences in motor function and at assessing microsurgical skill. Another possible explanation could be related to the fact that experienced trainees may have a faster learning curve compared with juniors, and may thus perform better on the 1-mm vessel after having practiced once on the 3-mm vessel. Experienced trainees took less time to complete the 1- and 3-mm microanastomoses compared with nonexperienced trainees due to better understanding of the surgical equipment, smoother technique, and higher efficiency with needle insertion and knot tying. Our subjective rating scores correlated well with the NOMAT scale scores. However, even though it is commonly used in the evaluation of microsurgical performance, subjective rating does not provide trainees with constructive feedback as to what subskills they should improve. This fact justifies the need for a more objective assessment method that could provide the trainee with a baseline evaluation and with learning curves that could be used to efficiently direct training efforts. Focused training aimed at efficiently mending specific technical gaps (such as instrument positioning or a tying technique) is becoming increasingly essential, especially with the implementation of the resident hour regulations that include surgical training time as part of the 80-hour work week.

Interestingly, our results have shown that postdoctoral research fellows, who underwent extensive training on the microanastomosis module, scored higher than senior residents. This observation highlights the importance of deliberate practice in neurosurgical training, especially if progress can be tracked in an objective fashion after every trial. Our assessment scale can potentially be taught to laboratory technicians who can provide constructive feedback to trainees. Additionally, videos of varying levels of performance can be posted on the web and accessed by all trainees. The feedback provided via a web-based methodology or a technician could potentiate deliberate practice. In his pioneering work on the acquisition of expert performance, Ericsson emphasized the importance of deliberate practice toward achieving and maintaining mastery.12–14 Kaufman and colleagues further stressed the importance of practice and repetition in psychomotor skill learning.22,37 In a randomized controlled evaluation of the performance of cardiothoracic surgery trainees on a microanastomosis module, Price et al. reported significantly better performance for trainees who underwent deliberate practice.32 The study highlighted the importance of deliberate practice in acquiring surgical skill and further stressed incorporating it into future simulation-based surgical curricula.32 A larger sample size or a multiinstitutional randomized controlled study may help further elucidate the importance of deliberate practice in neurosurgical training.

Face validity of the microanastomosis module has been established based on the evaluation of 2 experienced vascular neurosurgeons (B.R.B. and H.H.B.). Although very subjective in nature, this type of validity is important to ensure that the module mimics reality closely, and that the overall feel of the procedure is not far from what is experienced in the actual operating theater. The surgical setting, instruments, and artificial vessels used in the microanastomosis module were all deemed to realistically recreate a bypass procedure.

The purpose of our study was to provide neurosurgical residents and their mentors with a standardized tool that would enable them to assess their skill, pinpoint their technical weaknesses, and address them individually. We realize that even though this scale attempts to objectively rate performances by deconstructing complex tasks into simpler elements and general surgical principles, the Likert design that it follows does involve a minimal degree of subjective rater bias. Additionally, our scale did not detect significant differences between the performances of novices and experts using the 3-mm vessel. This may largely be due to the fact that our study population, even though inclusive of a large neurosurgery program, is still statistically small and underpowered. Repeating the study with multiple centers involved may provide more significant results. However, the goal of this study was to prove the feasibility of using the scale to detect differences in technical skill. Finally, we did not include faculty performances in the current study because the 2 main vascular neurosurgeons at our program were needed to direct resident testing and took part in designing the assessment scale, and were thus subject to the Hawthorne effect. The Hawthorne effect is the improvement of performance on a specific task based on a prior knowledge of what is being studied.1,29 Intra- and interrater reliability were not assessed in this study but will be evaluated in a separate study to show whether the NOMAT scale can produce similar results on repeated trials and among different raters.

Conclusions

A validated simulation curriculum is needed in the field of neurosurgery. We developed a validated bench module for the assessment of microsurgical performance of neurosurgical trainees. The scale differentiated between novice and expert performance and provided participants with a baseline score of their technical ability. Future efforts will need to focus on assessing interrater reliability and the impact of the scale and module on performance in the operating room. The assessment of interventions and varying educational strategies as well as the impact of deliberate practice on performance should be assessed as well. Multiinstitutional cooperation will be necessary to achieve these goals.

Acknowledgments

We thank William Kunkler and Susan Crown, as well as Dr. Joseph and Mrs. Nadia Tamari, for their generous support of the microanastomosis simulation laboratory at Northwestern Medicine.

Appendix

This article contains an appendix that is available only in the online version.

Author Contributions

Conception and design: Bendok, Aoun, El Ahmadieh, Batjer. Acquisition of data: Bendok, Aoun, El Ahmadieh, El Tecle, Daou. Analysis and interpretation of data: all authors. Drafting the article: Bendok, Aoun, El Ahmadieh. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Bendok. Statistical analysis: Bendok, Aoun, El Ahmadieh, El Tecle. Administrative/technical/material support: Bendok, Aoun, Batjer. Study supervision: Bendok, Aoun, Batjer.

Supplemental Information

Previous Publication

Portions of this work were presented in abstract form at the 2013 Neurosurgical Society of America annual meeting at Sea Island, Georgia, on April 8, 2013.

Current Affiliation

Dr. Bendok: Department of Neurosurgery, Mayo Clinic Hospital, Phoenix, AZ.

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Article Information

Correspondence Bernard R. Bendok, Department of Neurosurgery, Mayo Clinic Hospital, 5777 E. Mayo Blvd., Phoenix, AZ 85054. email: bendok.bernard@mayo.edu.

INCLUDE WHEN CITING Published online February 6, 2015; DOI: 10.3171/2014.12.JNS131814.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    A: Photograph of the microanastomosis laboratory, including the surgical microscope, operative desk, camera, and video recording setup. B: Photograph of the microsurgical kit. C: Photograph of the petri dish, red dye, and fluid pump. Figure is available in color online only.

  • View in gallery

    Camera 1 capturing de-identified operator positioning and posture (inset) and Camera 2 capturing the operative field under the surgical microscope. Figure is available in color online only.

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