Over the past decade, there has been rising concern that some surgical residents are not competent to enter independent practice by the time they complete their residency training.¹ Recent graduates of U.S. urology residency training programs express a lack of confidence in performing procedures commonly encountered in general urological practice. For example, 61% of young urologists report they do not feel prepared to perform a robotic radical prostatectomy, an index procedure per the Accreditation Council for Graduate Medical Education case log requirements for urology.² The majority of recent surgical graduates also seek fellowships, which may reflect the need for further training after residency.³ Additionally, decreasing autonomy in surgical residency can contribute to the lack of readiness for independent practice.⁴ Multiple forces are at play for meaningful learning in the operating room: work hour restrictions, expanding residency program requirements, regulations surrounding supervision, and pressure to improve clinical throughput, all within a fixed length of training.

Dr. William Halsted’s century-old principles of surgical training remain relevant today, including acquisition of technical skills through graded enhanced responsibility and independence. How trainees achieve that responsibility has shifted from pure discovery learning (learning by doing) to a need for guided discovery learning, in which an expert provides the novice with preparatory information before the experience, offers verbal and perhaps even manual guidance during the experience, and delivers feedback afterward. Learners using guided discovery learn more quickly, more accurately and are more likely to remember what they learned when compared to those who use pure discovery learning.⁵ Guided discovery learning partners well with deliberate practice to improve performance, and core to this partnership is the concept of feedback.

Figure. SIMPL data demonstrate development of operative autonomy and performance in urology residency training.

Learners who receive regular feedback about their performance perform significantly better, develop better judgment, and learn faster.⁶ Feedback not only fuels but accelerates learning. More importantly, the quality of feedback is essential to propel skill development. At the very least, feedback should be specific and encouraging. Effective feedback should additionally be corrective, rectifying undesirable or even harmful habits; speak to entrustment, defining learners’ independence with respect to expected level of performance; and design a learning plan for skill development, providing a recommendation on how to address a particular learning goal.⁷

The recent development of workplace-based assessments provides opportunities for delivering more formative feedback. Workplace-based assessment (WBA) comprises evaluation methods involving direct observation of routine clinical practice and has become a central component of competency-based medical education. Compared to more traditional assessment methods such as simulation and end of rotation evaluations, WBAs can better capture real-world clinical skill performance in real time, all while drawing views of multiple diverse raters. These assessments have been particularly effective in surgical specialties in which direct observation of procedures can be recorded instantaneously.

Communicating feedback in a timely, high-volume manner using WBAs has posed some challenges, not the least of which are time constraints and cumbersome delivery systems. The most cost-effective model of assessment is to ask faculty already working with trainees to assess their performance, but they must do so without significant disruption of their normal work flow to guarantee completion of the assessment. Technology in the form of web-based instruments and smartphone apps addresses the logistical barriers to implementing WBAs in surgical training.

The Minute Feedback System (MFS) is a web-based feedback tool developed to deliver more frequent, timely and meaningful feedback to medical students on their surgical clerkship. Medical students and faculty alike have found that the MFS is easy to use, encourages same-day assessment, and increases the quantity of documented feedback. Over 80% of students believe the MFS facilitates their receiving more formative feedback, and over 70% find the feedback useful for improving their surgical performance.⁸ One disadvantage of this system, however, is that it relies on logging into a computer to complete, which can be inefficient and burdensome.

Apps such as SIMPL (System for Improving and Measuring Procedural Learning) now afford educators and learners alike a mechanism for delivering and receiving dictated feedback literally in their back pocket. Smartphones make it possible to collect and use ratings of observed performances while adhering to evidence-based best practices, such as recording an assessment close in time to an observed performance. These real-time assessments have proven superior to end-of-rotation assessments in providing constructive critique for the surgical resident.⁹ Furthermore, having readily accessible performance data allows faculty to monitor trainee skill development so they can better individualize the teaching they provide and trainees to review their own data so they can guide their own learning objectives (see figure).

Current urology graduates express low confidence in executing specific procedures, namely robotic prostatectomy and percutaneousnephrolithotomy, that are performed in high volume by today’s urology workforce.¹⁰ Implementation of workplace-based assessments that target skill development in these particular procedures could help ensure our young urologists reach competence by the time they enter practice. Benjamin Franklin said, “Tell me and I forget. Teach me and I remember. Involve me and I learn.” Involving our trainees in their skill development warrants a symbiotic educational relationship in which teacher and learner work together to target individualized goals. Leveraging technology to improve the quantity and quality of surgical skill assessments will lay the foundation for a more competency-based educational system as we prepare the next generation of urologists for practicing surgery safely and competently.