Journal of Surgical Simulation 2021; 8: 44 - 52

Published: 16 December 2021


Original article

Can NOTSS methodology improve ACGME competencies when combined with simulation-based education?

Eugene Tuyishime, William D. Watson and Edward Dominguez
Corresponding author: Eugene Tuyishime, 3440 Olentangy River Road, Columbus, OH 43202, USA. Email:


Background: An expanding neck hematoma after thyroidectomy is a rare complication requiring urgent airway management and potential bedside evacuation before definitive surgical management. During our review of the literature, no evidence of an adequate teaching method for the management of post-thyroidectomy hematoma for novice learners was found. This study aimed to determine if Non-Technical Skills for Surgeons (NOTSS) methodology can improve Accreditation Council for Graduate Medical Education (ACGME) competencies when combined with simulation-based education.

Methods: This study used a randomized controlled study design to evaluate the performance of ACGME competencies among two study groups. The intervention group participated in a 30-min NOTSS lecture and a 25-min simulation scenario, and the control group participated in a 25-min simulation scenario only. A follow-up scenario was conducted to evaluate residents’ performance in neck hematoma management. The study’s primary outcome was participants’ total performance scores on the six ACGME competencies (patient care, medical knowledge, interprofessional and communication skills, professionalism, practice-based learning and improvement, and systembased practice).

Results: This study did not show a statistically significant difference in the total performance scores on the six ACGME competencies among the two study groups (35.2±3.62 versus 31.7±3.75; P=0.077). In addition, there were no statistically significant differences in the performance scores for any of the six ACGME competencies.

Conclusions: This study failed to confirm our hypothesis that NOTSS methodology can improve ACGME competencies when combined with simulation-based education. A study with a bigger sample size and a higher number of observable events may be necessary to have the power to detect a statistically significant difference. In addition, there was a long delay in the study due to the Coronavirus-19 pandemic. Less retention of skills in the intervention group may have changed the results of the study. Some of the later evaluation scenarios were done under the rules of social distancing which could alter the efficacy of the teaching.


neck hematoma; non-technical skills; simulation-based education

Additional Information

Supplementary material. Appendix 2 is available at: