Modern training methods for surgery have undergone a paradigm shift in recent decades and encompasses many challenges including surgeon-specific outcome reporting, reduced staffing levels, risks of legal recourse and increased financial pressures. Validated assessment tools are not routinely utilised in surgical practice. The measure of performance changes from objective assessment in trainees to evaluation of generic clinical outcomes and local processes for experts.

Research in the field of evaluating the relationship between performance assessment and clinical outcomes in general surgery is limited. Studies conducted to date are of a high variability and include relatively small numbers. Despite this, there exists a relationship between performance assessment scores and clinical outcomes using the measures of procedure duration, complication rate and length of stay.

The views held by all key stakeholders including trainees, trainers and the public were examined. Novel methods of training are not being uniformly utilised. The value of simulation training is unclear due to a lack of objective evidence; however, the public believe that this is mandatory prior to a patient encounter. There also exists a desire for regular performance assessment as a quality assurance of surgical practice.




An evaluation of the relationship between performance assessments, in both technical and non-technical domains, and clinical outcomes was conducted whilst controlling for various clinical and expertise-based variables. No clear relationship with clinical outcomes was found although there was a trend towards significance with composite scoring. Unit-based scores also demonstrated similar variability. Trends were observed in temporal analysis, but these were not statistically significant. Motivational factors also have an impact upon clinical performance and further research is required to evaluate the degree of impact.

This thesis has highlighted key areas where more research is needed to formally identify how to assess performance amongst surgeons in a method that has an evidence-based clinical impact.