Response to Letter From Bookless et al

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The authors would like to thank Bookless et al1 for their constructive critique of our randomized controlled study of video-based coaching. The authors appreciate their acknowledgment of the challenges faced when conducting randomized controlled trials in medical education. Bookless et al correctly highlight the importance of long-term skills retention following the intervention of a coaching program. Although the GROW (Goals, Reality, Options, Wrap-up) video-based coaching intervention reported in the study was a short intensive program, the authors would envisage the clinical implementation of a video-based coaching program to be an ongoing program that can increase or reduce its intensity as required during a trainee's progression. Nevertheless, the authors agree the question of long-term skill retention is an important one that warrants further study, with respect to video-based coaching interventions.
Bookless et al focus on the potential benefits of surgeon self-assessment of performance and correctly identify that the control group in our study were not permitted to review video recordings of their performance. It is important to clarify that self-assessment is a fundamental component of the GROW coaching framework, which formed the intervention tested in the study. The Reality stage was based on self-assessment of performance using validated global rating scales and watching the recorded video performance. Therefore, allowing the control group to perform self-assessment would have allowed them part of the intervention being tested. Furthermore, there is evidence of poor correlation between trainee self-assessment and expert assessment of technical skill2, so the benefits of self-assessment as a tool to improve laparoscopic skills in isolation are likely to be limited.
The authors share Bookless et al's disappointment that video review of operative performance is not readily available in current clinical practice. This is a challenge that could potentially be overcome, but will require institutions to invest in resources such as adequate recording hardware and secure data storage facilities in addition to the expected audio-visual workspace facilities required. These are the same equipment resources that would be required for video-based coaching. Bookless et al are correct to highlight that the faculty resources required for coaching will be challenging, and self-assessment with video review may reduce some of the faculty time required. This is something the authors suggested when discussing ways to optimize the feasibility of video-based coaching. The authors would, however, caution against attempting to dilute the tested coaching intervention by removing faculty participation altogether. Bonrath et al's3 recent coaching study provided evidence that trainee self-assessment improved in its accuracy following 2 rounds of structured coaching. Therefore as Bookless et al acknowledged, self-assessment is likely to be a learned skill in itself.
In summary, although the authors agree that self-assessment may have a role in laparoscopic skills training, self-assessment is a skill in itself, which could be taught as part of a video-based coaching program. This may facilitate long-term skill retention and reduce the intensity of faculty involvement for a long-term coaching program.
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