Discussion

Although otolaryngology is one of the largest surgical specialties globally, comparatively little research has been undertaken on the non-technical skills of doctors working in this field, or on the applicability and potential benefits to the specialty. The work that has been undertaken has been performed in simulated environments, in either single institutions or on national otolaryngology emergency courses for trainee surgeons.

However, useful conclusions can be made from this initial work. Otolaryngology trainees appear to have good skills relating to ‘situation awareness’, and can gather and understand information quickly and thoroughly. Whilst this is important for all emergency presentations, it is especially important for those involving patients’ airways, given their time-critical nature, particularly in children. The good skills demonstrated in anticipating how situations will develop and preparing for these are important in resolving emergency situations promptly, and can reassure other health professionals and trainees’ senior colleagues. The mean scores reported by Wu et al.^{Reference Wu, Kim, Fung and Roth20} and Sahovaler et al.^{Reference Sahovaler, Eibling, Bruni, Duvvuri, MacNeil and Nichols19} show that trainees’ leadership skills were marginally better than decision-making, communication and team-working (2.5 vs 2.3). Although determinations are difficult to make based on only two studies, these may be areas where further training and encouragement are required for this group of otolaryngologists. However, these are skills that do improve as progress is made through training programmes and as doctors’ general experience grows.^{Reference Gostlow, Marlow, Thomas, Hewett, Kiermeier and Babidge21}

The review also suggests that behaviour assessment tools other than the Non-Technical Skills for Surgeons tool may have a role in ascertaining otolaryngologists’ non-technical skills. The use of the Anaesthetists’ Non-Technical Skills behaviour assessment tool, as reported by Chang et al.,^{Reference Chang, Chou, Lin, Huang, Shih and Wu18} is arguably more suitable for assessing skills during those airway emergencies or intra-operative airway complications that contribute to an otolaryngologist's workload. This would be as relevant for those who encounter such issues both regularly and only on occasion, based on the nature and extent of individuals’ specialisation. It could also be relevant for those working in centres with a heavy burden of craniocervical trauma.

Assessing non-technical skills appears to be straightforward, although arranging additional training for multiple raters, and providing video-recording facilities to improve score validity and eliminate observer bias, is costly and time-consuming. These factors may dissuade others from performing further research in this area. However, the importance and growing awareness of non-technical skills does offer a convincing argument for resources to be provided for this work, especially given the comparative lack of evidence in otolaryngology.

A number of articles that were rejected during the Preferred Reporting Items for Systematic Reviews and Meta-Analyses selection process do discuss the assessment of non-technical skills during simulation-based training courses aimed at otolaryngology trainees. These articles were excluded because of insufficient information on assessment outcomes; however, their content suggests that the observation of surgeons’ non-technical skills in otolaryngology – head and neck surgery is possibly more widespread than the results of this systematic review suggest. Post-scenario debriefings, where participants’ demonstration of non-technical skills are discussed and their preparation for emergency airway interventions are assessed, were reported by Amin and Friedmann^{Reference Amin and Friedmann22} and by Hogg et al.^{Reference Hogg, Kinshuck, Littley, Lau, Tandon and Lancaster23}

Nguyen et al. describe 20-minute debriefing sessions following each of 19 different airway simulation scenarios, where trainee surgeons reflect on their reasoning for particular courses of action and their decision-making.^{Reference Nguyen, Bank, Fisher, Mascarella and Young24} These debriefing sessions are enhanced by the viewing of video recordings made of participants during the scenario.

Hall et al. report on the training and assessment of trainee surgeons’ non-technical skills during a simulation-based laser surgery and laser safety course.^{Reference Hall, Okhovat, Milner, Montgomery, Hitchings and Kunanandam25} Participants’ knowledge, use and correct completion of a pre-operative laser safety checklist were assessed, as was their management of an airway fire secondary to laser use. These articles do provide a useful example of how to assess non-technical skills during a practical course, and demonstrate how otolaryngologists can design and construct scenarios where the aim is to exclusively assess such skills.

Further work in two aspects of non-technical skills in otolaryngology would be useful. First, assessing senior surgeons’ skills would offer this group the opportunity to reinforce areas of strength and provide training in areas where improvements may be required. Yule et al. identified that surgical consultants from five different specialties had higher scores on the Non-Technical Skills for Surgeons tool (and thereby greater non-technical skills) than reference ratings from trainees for six different scenarios.^{Reference Yule, Rowley, Flin, Maran, Youngson and Duncan8} It is important to determine whether senior otolaryngologists’ skills reach the same level as those in other specialties and to establish points of learning from other fields of surgery. Non-technical skills assessment can also contribute to surgeons’ lifelong learning and appraisal processes.

Second, the ‘boot camp’ model of otolaryngology training, whereby established trainers and more junior trainees interact in a simulated emergencies training environment, has the potential to be adapted for non-technical skills assessment for both groups. Such boot camps are well-established in the UK and throughout the world. These models have proven to be adaptable enough to include new techniques of training and assessment for different levels of experience.^{Reference Chin, Chin, Roth, Rotenberg and Fung26–Reference Kovatch, Wertz, Carle, Harvey, Bohm and Thorne28}

Assessing non-technical skills during actual, non-simulated surgery has demonstrated benefits in hepato-biliary and pancreatic surgery, and in transplant surgery, as it can identify issues that would not have manifested during testing in a simulated environment.^{Reference Siu, Maran and Paterson-Brown29} This has particular potential during the longer and more demanding operations undertaken in otolaryngology; for example, skull base surgery, or head and neck oncological resections with free tissue transfer reconstruction, particularly as the skills of multiple operators could be assessed and constructive feedback provided to improve overall surgical performance.