Raising the Standard: Enhancing Quality and Safety through Real-time Feedback and Education

| August 1, 2020

by David Pechman, MD, MBA; Anthony T. Petrick, MD, FACS, FASMBS; and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Pechman is a Bariatric and Minimally Invasive Surgeon at Southside Hospital, Hofstra/Northwell in Bay Shore, New York and Assistant Professor of Surgery at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Dr. Petrick is Quality Director, Geisinger Surgical Institute; Director of Bariatric and Foregut Surgery, Geisinger Health System, Danville, Pennsylvania. Dr. Gadaleta is Chair, Department of Surgery, Southside Hospital; Director, Metabolic and Bariatric Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2020;17(8):18

In order to deliver safe and effective surgical care, every surgeon must have the opportunity to learn operative techniques and to continuously enhance his or her technical skills. Modern technology has improved access to evidence-based medicine, allowing physicians to more easily stay up to date and offer their patients the highest quality care. Similarly, remote video assessment provides surgeons with a powerful tool that can be used to augment surgical education during training and throughout a surgeon’s career.

As a result of the COVID-19 pandemic, many elective cases have been delayed or canceled, resulting in less exposure to operative cases for trainees. At this time, more than ever before, tools to improve technical coaching and education are needed to maximize the value of every surgical procedure for all trainees.

Video-based coaching (VBC) is an ideal method for learners to maintain access to mentorship and guidance to enhance their technical skills. VBC describes a relationship between a surgical trainee and a surgeon coach. Video-recorded procedures are shared, and the coach examines the cognitive, technical, and interactive performance of the trainee. The coach sets goals for the trainee, evaluates progress, and plans strategies to correct weaknesses and improve overall flow of the procedure. The utilization of VBC is increasing. A recent systemic review and meta-analysis conducted by Augestad et al1 concluded VBC improves trainee performance as assessed by objective technical performance scales.

Augestad et al screened 627 studies and ultimately included 24 that met eligibility criteria. All included studies were full manuscripts that described trainees undergoing VBC sessions with a video review in the perioperative period. Each included study was a randomized, controlled trial, and each one assessed improvement in surgical skill with an objective technical performance scale. Thirteen studies included medical students as study participants, while 11 studies included residents as study participants. Control participants received master-apprentice model training or no additional training.

VBC varied between studies. Some used a structured coaching framework while others did not. Timing of coaching varied from preoperative (most common, n=11) to intraoperative to postoperative. In all studies, procedural complexity was increased based on trainee experience level, and objective performance scoring scales were used. To standardize the results, the authors performed a random effects meta-analysis to evaluate the average effect across all studies. In their meta-analysis of the 24 studies, the VBC group (n=386) showed increased improvement in performance compared to the control group (n=392). VBC was effective in the preoperative and postoperative settings.

While VBC offers clear benefits to surgical trainees, it can also enhance the performance of surgeons in practice. One example of remote video assessment, the Crowd-Sourced Assessment of Technical Skills (C-SATS) system, captures video of surgical procedures, which is assessed by experts who grade various steps in a procedure, enabling a surgeon to identify areas for improvement.

A surgeon participating in C-SATS can submit intraoperative video for review by expert surgeons. The surgeon will then receive a report containing specific feedback on operative technique and safety aimed at enhancing a surgeon’s skill and improving patient outcomes. The entire video is available for review, as well as clips for step-specific analysis. The information includes an overall score and comparison to other surgeons within a specialty. The surgeon receives an individual score for each step and for each skill, a side-by-side comparison of a surgeon’s video to high-preforming videos. Quantitative and qualitative feedback from top-performing experts in the field is provided, and targeted case studies are available to supplement learning. In addition, the surgeon has the opportunity to request telemonitoring sessions with experts in their field.

Reviewing one’s own video recording of cases is always instructive, but it is much more productive when accompanied by expert review from peers. Major correction in technique or small suggestions regarding tissue handling or instrument selection provide opportunities for improvement. Remote video assessment provides an effective platform for instruction and mentorship. Although these assessments may be used for quality review or credentialing, it is our opinion that the process is best suited for longitudinal evaluation for trainees to supplement the instruction they get bedside in real time.

The practice of surgery requires the acquisition of a series of complex skills, all of which require “deliberate practice” to master.2 During training, residents received graduated autonomy and perform increasingly complex tasks as they progress. Lectures, video demonstrations, and simulations are all useful, but ultimately, the art of surgery is learned by operating. The COVID-19 pandemic has, at least temporarily, limited face-to-face interactions of all kinds including surgical training. The pandemic has only compounded the pressures that volume and financial expectations had already created for mentors and surgical trainees.

The recent establishment of VBC and C-SATS as highly effective tools gives surgical trainees the ability to continue learning and to maximize the educational value of every operative case. Utilizing this technology and connectivity is also critical for lifelong learning. Whether a surgeon is in training or has been in practice for decades, assessing performance is imperative as new instruments, technology, or procedures evolve into standard of care. VBC and remote video assessment are both effective mediums through which all surgeons can maintain and improve their skills.


  1. Augestad KM, Butt K, Ignjatovic D, et al. Video-based coaching in surgical education: a systematic review and meta-analysis. Surg Endosc. 2020;34(2):
  2. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15(11):988–994.


Category: Past Articles, Raising the Standard

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