Serving Time: Let’s Move to a Competency-Based Training Model

Surgical training is, and will forever remain, in a never-ending metamorphosis. This is the beauty and the exasperation of a field that continuously challenges the standard and pushes its own boundaries. Our roots are those of barbers, gifted with the precise sharpness of the knife, the unshakable steadiness of our hands, and the courage of trailblazers. Yet, we hold inside the tender thirst for knowledge and a passion for the intricacies of the human body. Indeed, our roots belong equally to the first Egyptian surgeons in 1800 B.C. who documented their practices on papyrus; to Leonardo DaVinci and his beautifully insightful outlines of human anatomy; to John Hunter and his methodical descriptions of organ systems; and to William Halsted, whose confidence and leadership have defined the surgical field we know today.

The societal fascination with the essence of surgeons has continued fervently even to this day, where despite being acknowledged as talented physicians, we are equally separated by our title of “surgeon” and “physician.” Old proverbs describe us as bestowed upon with “an eagle’s eye, a lion’s heart and a lady’s hand,” and a myriad of books have been written in an attempt to understand how modern-day surgeons have defied the status quo and evolved over the centuries. Despite being grounded in the pursuit of medicine and treating disease through surgery, the field has remained in a state of flux: always eager to incorporate new knowledge, to adopt innovative technologies, and to push the limits of what is humanly possible. It is not surprising that the field of surgical education is equally in a constant state of transformation and self-renewal, as it tries to breathlessly catch up with the existing needs, relinquish antiquated practices, and eagerly anticipate the future. It would be equally naive and arrogant to insinuate that surgical education will ever achieve a final state of being.

Despite the seemingly constant refinements from year to year, the training of surgeons will forever need to be improved upon in order to respond to the necessities of the field. Operations that were once routine have now become obsolete. Techniques that were once standard maneuvers have now been forgotten and replaced by modern tools. Living in a paradox that cherishes tradition while embracing cutting-edge technology, surgeons are defined at their core by “versatility.” My mentors have traversed an earth-shattering revolution of operative techniques from the introduction of electrical devices to improve coagulation of the tissue, to laparoscopy, endovascular and now robotic surgery. Traction-countertraction, an elegantly simple and fundamental principle of surgery, mirrors the parallel growth of the field of surgery with the field of surgical education that inevitably must respond with an equal and opposite force.

The past decades have in some ways remained frozen in time. While we have successfully removed ourselves from the Halstedian mentality of training, we have entered in many ways another extreme—that of serving time. Whether pushed by practical convenience or by tradition, the idea that a certain number of years must be spent in training has remained a rigid standard across the nation. What seems apparent, however, is that surgeons are as heterogeneous as the patients they treat. Despite attempts at standardizing their competency at the end of training, the current system does not allow for any flexibility in adjusting duration of training to address the infinitely variegated abilities of residents. Training for five clinical years ensures nothing more than a physician body in-house or across the table, but speaks nothing as to the talent and expertise of that surgeon to be.

Admission to a surgical residency does not include a test of manual dexterity, for example. As such, there is an unavoidable mix of surgical residents who struggle and some who excel. Pretending that fine dissection required in laparoscopy while watching a screen should be as second nature or equally challenging for every resident is presumptuous at best. If the field of surgical education is in need for one change today, it is that of competency-based training. The 850 cases required by the Accreditation Council for Graduate Medical Education to graduate surgical residency are regrettably arbitrary, as it does not ensure any quality of the work. A resident may log enough numbers, but nevertheless be incapable of reproducing a sublimely elegant and simple operation in a way that is safe and efficient. Conversely, her colleague might demonstrate a manual dexterity that surpasses that of her classmates. Ultimately, being a surgeon requires an excellence of the craft in a strictly proficient and perfectionistic manner. Unlike any other specialty, a millimeter, the hesitation of a gesture, a tremor, an ever-so-slightly overly pressured touch, can delineate life from death. Creating the surgeons of the future requires attention to the individual as much as it does to the group. Some residents are inherently talented and should be rewarded with shorter training that allows them to advance to the next steps and grow beyond the basic requirements. Others need more support and time to achieve the much-needed skillfulness of the craft.

Competency-based training in surgical residency should not be a feared utopia. Quite the contrary, it would be an objectively based incessant and real-time evaluation of each trainee, with the ultimate goal of nurturing each talent and addressing each weakness individually. If the objective of graduate surgical training is to create the absolute best surgeon that one is capable of becoming, then we ought to refrain from aggregating all residents within the same artificial time constraints, and instead focus on raising each one of them upward from their starting level. The practicality of assessing each resident would not be burdensome or complex given the existing technology, virtual reality and simulation-based platforms that already exist, as well as the data regarding inter-grader consistency of operative evaluations.

In simplest terms, when a resident and the program faculty agree that a certain level of competency has been achieved, then providing the board with several videos of operations performed by the resident might be all that is necessary to ensure qualification to graduate. Ultimately, the bell curve will prevail, and while some trainees will finish sooner, others will train for longer. The extrinsic motivation to improve and excel will never be stronger, which in turn will act to increase competency. While the temporary perceived discrimination based on duration of training will come into question, this will be ephemeral as the end result will fundamentally ensure an equal minimal competency of all graduating surgeons.

The current state of training is such that the heterogeneity of trainees and training programs is perpetuated by a lack of standardization of operative competency. In other words, the current requirement of time and case numbers, without a standardized assessment of abilities, produces a much more discriminatory and heterogeneous pool of practicing surgeons. By contrast, competency training would allow surgical education to homogenize excellence, to continue to flow smoothly, and adapt to the ever-changing field of surgery.