Resident Training in 2009: Opinion Against Competence-based Residency Training 

Timothy P. Carey, M.D., FRCSC
London, ON

Residency training in the surgical specialties has a long history. Over the years educators have continually tried to refine the techniques used to impart the surgical knowledge and skills necessary to produce safe competent surgeons to serve society. Recently, a fairly radical proposal has been made with respect to the timing of surgical training. It has been suggested that surgical training time can be compressed by adopting a curriculum-based on attainment of specific competencies as a replacement for the traditional time-based curriculum. 


Competency-based training is predicated on the concept that there are different learning curves for individuals and that those differences should be recognized in medical education. It is proposed that after an individual succeeds in mastering a skill set in orthopaedic training, he or she should be certified in that aspect of training. In this model, the entire curriculum is broken into modules of training, and the progression through training is based purely on attainment of certification in each module until the total training is complete. In this way, the duration of training is variable for every resident, and obviously the more "advanced" trainee can finish in a shorter period of time.

On the surface this appears to be an attractive idea from a number of aspects. Certainly in these days of doctor shortages, the possibility of producing physicians in a more efficient and timely manner has appeal. However, upon closer examination of the concept, a number of potential problems become obvious and bring into question the feasibility of such an approach.

From a purely practical viewpoint, designing such a program would present major logistical challenges. At present, residents are a vital part of the patient care team. The inability to predict the time a trainee would spend on a given service would obviously have a significant impact on the organization of patient care in teaching hospitals. The resident's role would need to be supplemented by physician extenders and other allied health professionals, at significant additional cost.

Surgical training in particular is an extremely demanding undertaking in medical education. Not only are we trying to impart a breadth and depth of knowledge about clinical conditions, but we are also charged with developing the technical skills necessary to perform the required intervention. The technical aspect of surgical training can be likened to an apprenticeship, with a foundation of core skills developed by repetition and then expanded into ever more complex treatment schemes. Ultimately the apprentice becomes skillful enough to work without supervision, and then graduates to solo practice. Another analogy is that of an airline pilot, who, in order to develop enough skill to become certified as an expert requires a minimum number of hours flying in progressively more senior levels of responsibility. This is a particularly apt comparison, as in both flying and surgery; the task is one that has very serious consequences in the case of errors. To protect the public, rigorous training conditions are enforced and graded responsibility is an important component of training.

In the recent book "Outliers", Malcolm Gladwell explores the attainment of expert status in many different fields. One of the most important concepts he explores is the "10,000 hour rule", which refers to the recurrent theme in the backgrounds of all the experts identified. No matter what field of endeavour, the best of the best could identify a prolonged period of repetitive practice at their chosen activity totaling on average at least 10,000 hours. In addition there was a direct correlation in the level of achievement and the time spent in practice even at levels less than 10,000 hours. Is there any reason we should assume that this doesn't apply to orthopaedic surgery?

The most significant problem in competency-based training is likely going to be the development of appropriate assessment tools. The concept implies that a definable skill set exists and has been defined for each module, and that these skills can be objectively measured both accurately and reproducibly. While it is true that the educational literature demonstrates the ability to teach some surgical tasks efficiently and effectively in this modular fashion, for the large part these studies are focused on specific manual tasks, e.g. application of a plate to a bone. An accurate assessment of how many cases are required to achieve a passing grade for a specific competency has yet to be defined, and even a specific number of cases may not be sufficient to determine competence. Merely recording the number of total knee joint surgeries the resident has scrubbed in on, for example, will be useless information unless the degree of responsibility can be documented, and the outcomes of those specific cases graded objectively. The complexity of acquiring and interpreting this data is daunting to say the least, and many subspecialty areas have a much wider range of procedures to be considered.

A complete orthopaedic surgeon is much more than a technician, and the ability to develop the skills necessary to be a caring, empathetic physician able to accurately diagnose and treat the myriad musculoskeletal conditions that comprise a modern day orthopaedic practice is only achieved by exposure and repetition. 

The development of the CanMEDS framework was a direct response to the public demand for more approachable, engaged physicians. It is difficult to see how these important competencies such as communicator and collaborator could be "signed off" on at some time during training in isolation. It is only with repeated encounters with patients and their families, in progressively more responsible roles, that the trainee develops the ability to break the news about a diagnosis of a tumour, or comfort the family whose child has sustained a serious fracture, or discuss end of life care with the family of an elderly patient with a hip fracture. There is no substitute for experience in these situations, and only time will allow enough exposure for the trainee to become comfortable with this important role.

The goal of our training programs should be to produce as complete a physician as possible. Generally speaking, the residents that tend to stand out in training programs demonstrate excellent judgment and professionalism in addition to clinical acumen and surgical skill. The current training system, while by no means perfect, has evolved over many years to enable us to produce excellent orthopaedic surgeons, and should not be abandoned until there is clear evidence that similar results can be achieved with newer training methods.


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