For nearly a century, surgery has been taught with the use of an apprenticeship model. Residents work with faculty members on clinical rotations gaining experience while providing service to patients. The rotations have educational goals and objectives, but resident education primarily depends on the patients who present to the clinical service. The Residency Review Committee (RRC) in Orthopaedic Surgery and the American Board of Orthopaedic Surgery (ABOS) both specify a five-year residency program, identifying this training time as the end point to residency. The program director must provide a “ready to practice independently” attestation. Few residents fail to complete the program or remain in the program for additional training.
As a consequence of time-based training, residents completing the program vary in competence, with no mechanism to solve this unfortunate situation. As an example, surgical skills are acquired in the operating room over five years. The more skilled resident participates in more cases and is allowed more independence sooner than the less skilled resident who participates less and progresses more slowly. Although appropriate for patient safety and quality of care, this differential experience effectively widens the surgical skill gap between more and less skilled trainees.
With time determining completion of training, other educational landmarks are of secondary importance. A true curriculum is not necessary. Why work to define a body of knowledge or required set of skills if competence is defined as time in training? After five years, the training is done regardless of resident skills or knowledge. The assessments necessary to determine competence are less important than the time in training, and assessment on busy clinical services often plays a limited role.
The article by Ferguson et al.1 forces us to ask: is time the optimal determinant of the end of resident training and clinical practice independence? The authors present their experience with a modular curriculum that changes the paradigm from time-limited education to competency-based assessment of resident progress with competency-based end points. This experience is thought-provoking and fundamentally more logical than our current time-based system.
Competency-based training has important core features. First, a curriculum for orthopaedic surgery must specify the required skills and competencies. Second, robust and validated assessments must replace time in determining the end of training. Third, accelerated skills training must include surgical simulation in which residents acquire skills safely through dedicated practice and feedback, train to proficiency, and learn from errors. These core features of competency-based training are laudable and could be easily achieved in our current system.
Unfortunately, despite the appeal, there are obstacles to wide adoption of fully competency-based training. The RRC and the ABOS would have to eliminate mandatory time requirements and would have to replace them with validated assessments of competency. Graduate Medical Education (GME) funding in a competency-based training system, in which residents flow in and out of training positions that are not limited by time, would have difficult logistical hurdles and would be more expensive. Residents provide essential clinical service, making it difficult to direct them to competency-based educational needs and even more difficult to replace experienced residents who have achieved required competencies. Substantial additional resources would be required at a time when GME is already financially stressed.
Our current GME system is moving toward better defined and nationally accepted competency metrics. Procedural case logs and case-minimum categories are now mandated. Orthopaedic surgery milestones in all six competencies are in the first year of implementation. The ACGME-ABMS (Accreditation Council for Graduate Medical Education-American Board of Medical Specialties) is converting to the Next Accreditation System (NAS), which will be more data-driven and will better assess resident progress and program outcomes. Laboratory-based surgical skills training is now mandated for orthopaedic surgery and there is a modular curriculum at the postgraduate year 1 (PGY1) level.
Although these are important steps toward competency-based resident education, our current system is not yet ready to move away from time as the prime metric of completion of training. The experience described by Ferguson et al. remains aspirational, but it should inspire us to have an open mind to taking further steps in this direction.