According to the Greek writer Pausanias, the motto “know thyself” was inscribed in the forecourt of the Temple of Apollo at Delphi. Without getting overly spiritual, this ancient dictum can be an excellent starting point for surgeons who want (or need) to improve their technique. But how do surgeons gain insight into their technical failings to best understand where they need improvement? One simple way is to ask colleagues for constructive criticism. While this approach is easy enough in theory, the perils and pitfalls when seeking meaningful change are obvious.
Recording videos of cases and personally reviewing them with a critical eye is another option that is practical and has many benefits (I do it regularly and highly recommend it). However, it does introduce a huge element of observer bias; specifically, techniques that each of us may consider adequate may be viewed by others as suboptimal. Finally, a combination method might be to record cases anonymously and ask skilled observers to review elements of the procedures and offer their collective opinions as feedback to the operating surgeon. Nice idea but it seems sort of a “pie-in-the-sky” solution. Well, it may be that the pie has landed in the form of “Crowd-Sourced Assessment of Technical Skills,” or C-SATS.
Based on technology developed at the University of Washington by a team of physicians, software engineers, and biostatisticians, researchers in 2013 demonstrated that, using specific criteria, a group a 500 Internet reviewers were able to score a surgeon’s technique as accurately as 10 expert surgeons.1 C-SATS uses the power of the Internet to rapidly and reproducibly have surgical videos analyzed by a wide range of reviewers with a focus on a defined sets of skills, such as tissue handling, efficiency of movement, and bimanual dexterity.
Reduced to simple terms, surgeons submit videos of procedures to C-SATS, which the company edits to highlight specific areas in which specific skills are demonstrated. Next, the clips are sent to online experts and reviewers worldwide, who anonymously evaluate them using defined and accepted assessment tools, such as GOALS and GEARS. The results are then tabulated and quantified and qualified feedback is provided to the submitting surgeon within hours.
I submitted 4 separate videos of vaginal cuff closures at laparoscopic and/or robotic total hysterectomy to C-SATS. Within 12 hours, their analyses of all 4 procedures came back. I then reviewed my videos again against my performance summary from C-SATS to see what I thought of their analysis of my skills. I was impressed (with their analysis, not my techniques). I mostly agreed with their conclusions and thought the whole exercise was an outstanding, confidential self-assessment tool that will help me improve my technique so that I can offer better care to my patients.