RAS-ACS Symposium: Pro: Competency-Based Training: Is There Any Other Way?

Editor’s note: Following are the second-place pro 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 con article is available at https://bulletin.facs.org/?p=32136&preview=true.

If your family member needed an operation, what would you want in a surgeon? Although competency-based training (CBT) has been criticized for subjectivity in assessment or deemed as rushed training, I believe it should become the standard for surgical training, as it focuses on foundational learning, individualizes skill acquisition, and aligns with theories of learning psychology.


Recent literature has demonstrated concerns about the direction in which surgical training is headed because of a number of external restrictions or changes. A 2013 study reported that fellowship program directors recognized deficits in surgical training, noting that trainees often lack necessary operative ability and therapeutic knowledge, as well as an understanding of patient responsibility.1 In addition, a 2014 survey of residents demonstrated a notable lack of confidence in performing a variety of foundational surgical procedures.2

Previously, surgical training focused on operative volume as a surrogate for one’s quality of training without evidence. “Competency,” a concept that R.H. White introduced in 1959, is defined as “characteristics…that lead to acceptable or outstanding performance.”3 CBT is then a framework to help individuals build the requisite skills needed to align with success.3 Growing recognition for CBT as a means of improving performance has cemented its role across a variety of disciplines.

Nonetheless, CBT in general surgery has been criticized for advancing learners based on subjective measures with possible bias, implicit or not, and arbitrarily shortening training. This view is rather shortsighted, as there has been movement in surgical education and training toward implementing robust and objective methods of advancement, such as expert-derived benchmarks, blinded review, entrustable professional activities (EPAs), and potentially artificial intelligence (AI). Furthermore, a shift to competency-focus is not necessarily a shift away from time-focus but rather toward a learner-centric approach with skill acquisition and retention verification.

Focus on Foundational Learning

First, CBT focuses training goals on foundational needs. CBT requires the act of defining competencies; thus, surgical educators must first understand and define what they believe are the characteristics required for all successful surgical trainees and, subsequently, build training programs that reflect those needs. The Accreditation Council for Graduate Medical Education (ACGME) recognized this necessity by defining six core competencies that all residents should acquire. A joint ACGME and American Board of Surgery (ABS) initiative identified eight additional domains and 16 subcompetencies needed for surgical practice.4,5

Content experts recognized that a successful surgical trainee is able to care for disease and conditions, perform operations and procedures, complete assignments and administrative tasks, maintain physical and emotional health, teach, improve care, coordinate care, and self-direct learning.”5 We must then align the assessments and goals of training with the foundational needs of surgery.

A successful surgical trainee is able to care for disease and conditions, perform operations and procedures, complete assignments and administrative tasks, maintain physical and emotional health, teach, improve care, coordinate care, and self-direct learning.

Criticism of the vague wording of competencies and thus claims regarding the subjectivity of advancement is sound; however, these assertions ignore the recent strides in ensuring more robust advancement criteria. Blinded video-based reviews of operative performance have shown feasibility and reliability and a correlation with clinical outcomes.6-8 Furthermore, a growing body of evidence supports the future use of AI in providing objective assessment and intraoperative feedback to surgeons.9,10

Focus on Individualized Training

CBT also allows for a focus on individualized learning. Instead of defining training success by the number of months spent in a subspecialty or the number of operations in which a resident participated, the focus is on competency. For example, previous arbitrary benchmarks of laparoscopic skills training, such as time or number of repetitions, not only demonstrated significant variability in trainee performance but also identified plateaus and areas of trainee frustration.11 Instead, setting expert-derived performance metrics and guidelines for deliberate practice guarantees a level of required skill acquisition while allowing trainees the flexibility to self-train.12

This measurement system does not have to apply solely to skill acquisition. The development of EPAs by Olle ten Cate, MD, PhD, at the University of California San Francisco, are intended to provide a practical framework for evaluating the core competencies previously described on an individual level. EPAs represent units of professional practice that a trainee is trusted to perform independently and competently.13 Along with other tools, surgical EPAs can establish individualized guidelines for progressive autonomy, both within and outside of the operating room.13-15

An ongoing ABS-sponsored pilot program uses five EPAs, ranging from the management of the preoperative, intraoperative, and postoperative care of a patient with right lower quadrant pain or blunt or penetrating trauma to more general competencies, such as “provid[ing] general surgical consultation to other healthcare providers.”16 CBT does not assume that all learners will possess or attain all competencies. It does, however, allow both educators and learners to recognize areas of strength and weakness and subsequently tailor training; this represents the much-needed shift away from one-size-fits-all to learner-centric education.

Focus on Goal-Oriented Learning

Moreover, CBT methods are supported by the literature in learning psychology. By creating defined competency standards as the metric of success, CBT draws on goal-oriented learning theory. Examples include Lev Vygotsky’s zone of proximal development (ZPD), the K. Anders Ericsson, PhD, theory of deliberate practice, and the Stuart E. Dreyfus, PhD, and Hubert E. Dreyfus, PhD, model of skill acquisition.17-20 Studies support that goal-setting using competency benchmarks improves surgical skill acquisition in multiple levels of learners.21,22

When coupled with deliberate practice and immediate feedback efforts, CBT produces surgeons with shorter operative times, fewer errors, and better outcomes.

By establishing training benchmarks to help educators define the various zones in ZPD, educators can improve skill acquisition by scaffolding their support. Dr. Ericsson, an expert in learning and expert performance, states that competency and mastery are not mutually exclusive. When coupled with deliberate practice and immediate feedback efforts, CBT produces surgeons with shorter operative times, fewer errors, and better outcomes.19 The American College of Surgeons/Association of Program Directors in Surgery Resident Skills Curriculum was modeled on this very approach.2,3

The Dreyfus model of skill acquisition, which puts competency as a necessary step toward mastery learning, has further been applied beyond technical skill acquisition to understanding and evaluating patient complexity and performing a holistic review of clinical and technical care as well.20-24 Thus, by establishing standards of performance and training techniques, CBT can complement learning psychology efforts, such as setting goals, pushing skill acquisition based on learner needs, and establishing the foundations for mastery-based training.


CBT employs an evidence-based, foundational, and learner-centric approach to build skills that align with learning psychology and mastery-based training. Thus, when human life is in the equation, training competent surgeons should be the unquestionable goal. So, I ask again: What type of a surgeon would you want operating on your family? Surely, a competent one.


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  14. George BC, Teitelbaum EN, Meyerson SL, et al. Reliability, validity, and feasibility of the Zwisch scale for the assessment of intraoperative performance. J Surg Educ. 2014;71(6):e90-e96.
  15. Bohnen JD, George BC, Williams RG, et al. The feasibility of real-time intraoperative performance assessment with SIMPL (System for Improving and Measuring Procedural Learning): Early experience from a multi-institutional trial. J Surg Educ. 2016;73(6):e118-e130.
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  17. Kaplan A, Maehr ML. The contributions and prospects of goal orientation theory. Educ Psychol Rev. 2007;19(2):141-184.
  18. Vygotsky L. Mind in Society: The Development of Higher Psychological Processes. Cambridge, MA: Harvard University Press; 1978.
  19. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 Suppl):S70-S81.
  20. Dreyfus S, Dreyfus H. A five-stage model of the mental activities involved in directed skill acquisition. California University Berkeley Operations Research Center [monograph on the Internet]; 1980. Available at: https://apps.dtic.mil/sti/citations/ADA084551. Accessed January 24, 2022.
  21. Kishiki T, Lapin B, Tanaka R, et al. Goal setting results in improvement in surgical skills: A randomized controlled trial. Surgery. 2016;160(4):1028-1037.
  22. Gardner AK, Diesen DL, Hogg D, Huerta S. The impact of goal setting and goal orientation on performance during a clerkship surgical skills training program. Am J Surg. 2016;211(2):321-325.
  23. Scott DJ, Cendan JC, Pugh CM, Minter RM, Dunnington GL, Kozar RA. The changing face of surgical education: Simulation as the new paradigm. J Surg Res. 2008;147(2):189-193.
  24. Mitchell EL, Arora S. How educational theory can inform the training and practice of vascular surgeons. J Vasc Surg. 2012;56(2):530-537.

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