RAS-ACS Symposium: Con: Competency-Based Training: A Gateway to Efficiency or a Sprint to the Finish Line?

Editor’s note: Following are the second-place con paper submitted for consideration at the American College of Surgeons (ACS) Resident and Associate Society (RAS) Symposium debate at the virtual Clinical Congress 2021. The symposium took place Sunday, October 24, and centered on the topic of Competency-Based Surgical Training. First-place essays were presented virtually as part of that program. The second-place pro article is available at https://bulletin.facs.org/?p=32135&preview=true.

Surgical residency is a long, challenging path. Residents commit to 5−7 years of rigorous training with the goal of developing into safe, competent, well-rounded surgeons. Though shortening this time commitment via a competency-based program may sound appealing, such an approach ultimately detracts from creating balanced physicians and places undue emphasis on clinical proficiency alone.1,2 Complete surgeons are far more than the sum of their competencies.

Sum of All Its Parts

Surgical training is a collection of formative experiences beyond fixed didactic learning, meant to transform the green intern into a ripened surgeon.3

Despite diligently planned rotations and schedules, experiences within and across surgical residency programs vary widely. One resident may encounter and manage more of a particular diagnosis while on a specific surgical service, whereas others may only see the disease when rotating through that service at a later time. In the end, residents will meet the case requirements, though attainment of these numbers likely requires the prescribed number of clinical years to balance out intrinsic irregularities in case mix over time. Residents should not be penalized because of the order in which they encounter certain clinical experiences.

Though it is important to track the progress of residents as they proceed through residency, this approach to competency testing is flawed, as it cannot accurately reproduce the environment wherein the skill would typically be practiced.

Proponents of a competency-based program may argue that the variability of experience supports this training format. Advocates for competency-based education have suggested frequent knowledge and technical skills assessments to follow key rotations, for instance.4 Though it is important to track the progress of residents as they proceed through residency, this approach to competency testing is flawed, as it cannot accurately reproduce the environment wherein the skill would typically be practiced. Therefore, it is not reflective but rather an artificial assessment of true competence. This checkpoint strategy to skill and knowledge assessment may encourage a cramming mentality among learners. In other words, a resident may spend a disproportionate amount of time leading up to the examination preparing for the material being tested and, once complete, lose the motivation to maintain proficiency in that particular subject matter.

Additional Stress

Similarly, competency-based training adds an unnecessary sense of urgency for residents in an environment that is already highly stressful and demanding. Focusing solely on competencies risks shifting the focus of trainees away from acquiring a breadth of in-depth clinical experiences toward a “box-checking” mentality. It emphasizes a bare minimum approach when residents should be encouraged to achieve maximum potential.4 Residents should strive not only to become competent surgeons on paper, but also to embrace the experiences surrounding these competencies over the course of their training.

This is not to say that achieving a standard level of clinical and technical proficiency is unimportant for all graduating residents. Competency-based education supporters have emphasized the possibility of integrating entrustable professional activities (EPAs) into residency curricula, which are “units of professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised trainee once he or she has attained sufficient specific competence.”5

Limitations of EPAs

On paper, this approach appears to be an appropriate way to standardize and ensure competence among all residents. In practice, however, the implementation of EPAs has important limitations.

First, residents need to acquire numerous areas of proficiency over the course of training. Consequently, choosing distinct EPAs over others may inadequately reflect future practice for each graduating individual.

Second, although the EPA evaluation occurs in real time, the burden of conducting a comprehensive assessment of an entire clinical issue, inclusive of preoperative, operative, and postoperative care, is infeasible for all faculty and risks being interrupted or incomplete.5 This format demands excessive time and resource allocation that is probably unsustainable for all residents, across all postgraduate years, for all necessary competencies.

Finally, the direct observation component of the EPA may inherently produce a Hawthorne effect, wherein residents conduct themselves differently across the spectrum of operative care in moments where they are aware of being observed. Furthermore, it is difficult to ensure that faculty assessment of resident competencies remains fully objective and not influenced by a faculty member’s unconscious biases favoring some residents over others.2,6 A competency-based program would be highly evaluator-dependent, not only in terms of biases but also in terms of depth and specificity of assessment.7

Surgeon Identity Development

Clinical teaching and intraoperative decision-making cannot be entirely standardized and taught within the confines of a predetermined set of competencies. A lot of surgical teaching occurs informally or on the fly, such that encounters with a range of faculty across several years and through a breadth of cases cannot be completely formulaic. Beyond skill acquisition, residency is a time for graduated professional development and surgeon identity formation.8,9 Trainees evolve over the course of residency into their respective surgeon personas as they navigate subspecialty choice and practice preferences.

Though all general surgery residents must achieve a baseline mastery of surgical procedures, surgery in and of itself is stylistic and accommodates a range of practice approaches. Crucial to this development is the identification of role models and mentors throughout training from which a budding general surgeon can synthesize a unique career trajectory.10 A competency-based program risks limiting the time available for trainees to build these relationships and explore various opportunities to inform their future practice. As much as the competency-based approach is thought to tailor training to residents, one could argue that it hinders the opportunity for individualized career and surgical identity development.


Surgical training is a journey to promote the maturation of well-rounded surgeons. It involves the development and refinement of operative technique and clinical judgment. It also is a process of graduated professional development into one’s surgical identity through relationships within the working environment and concurrent career introspection.3,10 The journey cannot be fit into discrete competency boxes to be checked off, and doing so would be a disservice to patients, residents, and the surgical community as a whole. Surgical wisdom implies a timely and cumulative acquisition of knowledge, experience, and judgment.3,10 The attainment of such acumen cannot be replaced or guaranteed by condensed competency-based training.


  1. Hochberg MS, Berman RS, Pachter HL. Professionalism in surgery: Crucial skills for attendings and residents. Adv Surg. 2017;51(1):229-249.
  2. Meyerson SL, Odell DD, Zwischenberger JB, et al. The effect of gender on operative autonomy in general surgery residents. Surgery. 2019;166(5):738-743.
  3. Lipsman N, Khan O, Kulkarni AV. “The actualized neurosurgeon”: A proposed model of surgical resident development. World Neurosurg. 2017;99:381-386.
  4. Nguyen VT, Losee JE. Time-versus competency-based residency training. Plast Reconstr Surg. 2016;138(2):527-531.
  5. Brasel KJ, Klingensmith ME, Englander R, et al. Entrustable professional activities in general surgery: Development and implementation. J Surg Educ. 2019;76(5):1174-1186.
  6. Gerull KM, Loe M, Seiler K, McAllister J, Salles A. Assessing gender bias in qualitative evaluations of surgical residents. Am J Surg. 2019;217(2):306-313.
  7. Crannell WC, Brasel KJ. Dealing with the struggling learner. Surgery. 2020;167(3):523-527.
  8. de Montbrun S, Patel P, Mobilio MH, Moulton CA. Am I cut out for this? Transitioning from surgical trainee to attending. J Surg Educ. 2018;75(3):606-612.
  9. Di Napoli R, Sullivan N. Constructing surgical identities: Being and becoming a surgeon. In: Advancing Surgical Education: Theory, Evidence, and Practice. Singapore; Springer, 2019:123-131.
  10. Cope A, Bezemer J, Mavroveli S, Kneebone R. What attitudes and values are incorporated into self as part of professional identity construction when becoming a surgeon? Acad Med. 2017;92(4):544-549.

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