The question of training and promoting residents based on their competence rather than their years in the program is an interesting one.

Some people learn at different rates. I've seen residents who understand how to perform some operations after just a few repetitions and others who don't seem to get it after many tries.

This experience has led some to call for competency based training—that is, don't let them graduate until they are deemed competent in all phases of surgery. This is not to say that we let incompetent residents graduate in the past. But the current system says that when a resident has completed five years of surgical residency and is signed off on by the program director (PD), she may sit for the board exam.

If the PD didn't think a resident was ready after five years, she could try to arrange for some remediation, but there is no formal process. Obviously, it would be best if residents who are having problems are identified well before they are in their last year.

Competence-based advancement would possibly be an improvement but is fraught with problems.

Those who are kept from graduating would have to be paid. If keeping someone back adds extra residents to the program, how would they be funded? What happens to the case mix when you have, say, an extra PGY-4 around? Would there be enough cases for everyone to scrub on or would the educational experience be diluted for all?

How do you decide who to hold back? At what point in the academic year would this decision be made? What if someone is accepted to a fellowship and then has to be held back? What if someone seems very competent in only four years? Should that resident be allowed to graduate early? If so, the American Board of Surgery would have to change its rules.

Technical skills are not the only consideration. As I have mentioned in past posts, deciding who needs an operation, what operation to do and when to do it is even more important. Since residents are so closely supervised these days, they rarely have opportunities to make those kinds of decisions.

Competency based resident education has been talked about since at least the mid-1990s. A paper in Academic Medicine in 2000 describes an attempt at this type of training in the neurosurgery residency at Johns Hopkins. It focused on five procedures which seemed to be mastered more quickly in the competency based format.

However, from the description of the neurosurgery program now, it appears to be a standard seven years-five clinical and two research, which suggests that competency based training didn't work out.

There may be other issues that I haven't thought of.

What do you think of competency based training? Would it work?

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5900 followers on Twitter.