• Alexander Winkler-Schwartz, Ibrahim Marwa, Khalid Bajunaid, Muhammad Mullah, Fahad E Alotaibi, Abdulgadir Bugdadi, Robin Sawaya, Abdulrahman J Sabbagh, and Rolando Del Maestro.
• Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, McGill University, Montreal, Quebec, Canada. Electronic address: manuscriptinquiry@gmail.com.
• World Neurosurg. 2019 Jul 1; 127: e230-e235.

BackgroundAdequate assessment and feedback remains a cornerstone of psychomotor skills acquisition, particularly within neurosurgery where the consequence of adverse operative events is significant. However, a critical appraisal of the reliability of visual rating scales in neurosurgery is lacking. Therefore, we sought to design a study to compare visual rating scales with simulated metrics in a neurosurgical virtual reality task.MethodsNeurosurgical faculty rated anonymized participant video recordings of the removal of simulated brain tumors using a visual rating scale made up of seven composite elements. Scale reliability was evaluated using generalizability theory, and scale subcomponents were compared with simulated metrics using Pearson correlation analysis.ResultsFour staff neurosurgeons evaluated 16 medical student neurosurgery applicants. Overall scale reliability and internal consistency were 0.73 and 0.90, respectively. Reliability of 0.71 was achieved with two raters. Individual participants, raters, and scale items accounted for 27%, 11%, and 0.6% of the data variability. The hemostasis scale component related to the greatest number of simulated metrics, whereas respect for no-go zones and tissue was correlated with none. Metrics relating to instrument force and patient safety (brain volume removed and blood loss) were captured by the fewest number of rating scale components.ConclusionsTo our knowledge, this is the first study comparing participant's ratings with simulated performance. Given rating scales capture less well instrument force, quantity of brain volume removed, and blood loss, we suggest adopting a hybrid educational approach using visual rating scales in an operative environment, supplemented by simulated sessions to uncover potentially problematic surgical technique.Copyright © 2019 Elsevier Inc. All rights reserved.

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