assessors rated all three assessments alike, on all questions the median scores did not differ more than 0.5 points. With a median score of four more than half of the assessors agreed that the three assessments give a procedure specific competency level and (with a median of 2 - 2.5) do not lead to an unnecessary administrative burden. More than half of the expert panel (7/12) (strongly) agreed that the PBA and BOSATS (or a similar assessment) should be available for other procedures. Half of the expert panel agreed that the PBA and BOSATS should be used in clinical practice, as the OSATS already is. The BOSATS was considered most helpful in the acquirement of procedural knowledge and skills. DISCUSSION This study introduced a new created procedure-based assessment (PBA) for LRYGB using an independence scale combined with the key steps of the procedure. It was observed that the assessor can use the PBA on a videorecorded LRYGB procedure performed by a novice, intermediate and expert surgeon to differentiate their competency level. Thus, the PBA provides a relevant assessment of the trainee’s skills. This PBA sets apart from other procedure-based assessments, as the BOSATS, in the use of an independence scale instead of a specified level for each sub-step. This may make the instrument easier to read as well as more robust in slightly changing operative techniques. Moreover, by using only 30 predefined key steps for the whole procedure this may enhance usability and shorten the duration of the assessment. Compared to the OSATS, a global rating scale assessment, both this PBA LRYGB and the BOSATS show a smaller difference in scores on one specific sub-step, respectively the creation of the gastric pouch and the biliopancreatic limb and gastrojejunal anastomosis. However, if all videorecorded are steps combined, all three instruments can differentiate between the three proficiency levels. Implementing a procedure-based assessment can enhance both summative and formative feedback during surgical training.28 GRSs are valid instruments during training, however, their construct validity at senior training levels is debatable.13 For the OSATS scores in this study the same pattern was seen, as the OSATS was less able to discriminate between intermediate and expert level. 92 5
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