The figure of the surgeon has undergone a progressive transformation over the last two decades, as a result, on the one hand, of a number of substantial changes in clinical practice and, on the other, a certain degree of demographic and generational transformation.1 The need for development in facets of the academic field, the abandonment of a certain individualism when it came to forming an integral part of multidisciplinary teams, and even the abandonment of paternalism and the obligation to inform and agree on decisions jointly with patients and relatives,2 have brought with these changes the need to learn and perfect aspects that transcend individual knowledge, technical ability and accumulated experience.
Some of these new qualities that are promoted in their training are what has been coined as Non-Technical Skills for Surgeons (NOTSS). These could be defined as cognitive, social and personal resource skills that facilitate decision-making and performance, and that are especially relevant in environments that may be hostile or situations of potential risk.3 In addition, some authors suggest that there is a direct additive effect of the NTSS on the surgeon's own technical skills, achieving a direct impact on surgical results and professional development.4
The most important non-technical skills are categorised as follows:
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Leadership: this should be understood as the ability to achieve the best possible performance from the people who make up a team, also helping them to feel satisfied with their work. This leadership must also be exercised within the surgical teams, where the surgeon must be a leader who assists the rest of the operating theatre staff in performing their particular tasks effectively and rewardingly.
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Situational awareness: this is one of the skills that enables human beings to take relevant information from the environment that surrounds them and that helps them in decision-making and planning. The full development of this skill enables not only accurate interpretation of what is taking place around us at a particular moment but also should enable us to anticipate even what may happen in the future. In times of stress, the focus can be too concentrated on a particular task, causing cognitive overload, clouding our situational awareness, our ability to judge and, therefore, our ability to take decisions, this possibly becoming a specific danger in certain situations.
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Decision-making: in the field of surgery, decisions must constantly be made about the best behaviour for patients to adopt or the technical alternatives that could be applied, in an attempt to anticipate the results. This decision-making process can be systematised, learned, and transmitted.
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Communication: Most errors in the health care environment are due to communication problems. Improving our communication with the rest of the professionals who collaborate in the care of our patients is a fundamental aspect.
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Teamwork: The work carried out in health care environments is fundamentally team-based collaboration. It is important to promote a working environment in which all members are satisfied and fulfilled with their role.5,6
As interest in these NOTSs has increased, strategies have been developed to improve training in this area,7 on the one hand, and also scales that enable these skills to be measured.8 This makes it possible to assess the different training events, measuring their effectiveness in terms of the acquisition of the NOTSS. Having these measurement tools also makes it possible to monitor their development over time or compare results between the different training activities.
Originally, the scales designed were generic or from other specialties. Over time, measurement instruments have been developed that are specific to NOTSS.
Some of the most frequently used scales to measure non-technical skills are the Non-technical Skills for Surgeons system (NOTSS3; the Oxford Non-Technical Skills (NOTECHS); or the Observational Teamwork Assessment for Surgery (OTAS). The aspects that are assessed in these scales are listed in Table 1. The most widely used measurement instrument is probably the NOTSS system, which has been validated in different studies and can be used both in simulation environments and in daily practice.
Comparison of the aspects evaluated by the main scales for the assessment of the surgeon's non-technical skills.
| NOTSS | Oxford NOTECHS | OTAS |
|---|---|---|
| Situational awareness | Situational awareness | Situational awareness |
| Leadership | Leadership and management | Leadership |
| Communication and teamwork | Teamwork and cooperation | Communication |
| Decision making | Problem solving and decision making | |
| Coordination | ||
| Cooperation |
A striking fact is that, since their conception and classification, the NOTSS have not undergone any modification. However, taking into account that this field is nurtured by another that we could consider broader, that of cross-functional skills, it seems logical to think that in the coming years we will see how other disciplines or additional skills are added, such as innovation or the acquisition of digital skills, which are two of the other aspects that have undergone the greatest development and have a foreseeably broader projection in the short and medium term.
Finally, in view of all the above, there are several authors who have highlighted the lack of planning and preparation that exists in this field, both at the undergraduate stage9 and at the post-graduate level,10 and advocate a transformation in surgical training, integrating these types of NOTSS into the official curriculum from the earliest stages of medical education. Undoubtedly, the coming years will witness a new era in which all these aspects will be developed in an especially significant way.
