“See one, do one, teach one” has long been regarded as the gold standard by which medical trainees are introduced to clinical practice. Within general surgery, this idea of staged progression traces back to William Stewart Halsted, who famously provided graduated autonomy to selected trainees.1 There is no doubt that the Halstedian model of surgical education has left a significant imprint on the training of current surgical residents over a century later. However, as healthcare evolves, it is increasingly evident that our approach to surgical training must adapt in order to maximize the competence of graduating surgical residents.
Conversations with experienced surgeons about the current state of resident education often lead to some lament about how training is not as good as it once was. Barriers to surgical education have been extensively discussed and chronicled over recent years. Duty hour restrictions, increases in litigation and medical malpractice, numerous new surgical modalities (robotic, laparoscopic, endoscopic, etc.) to be learned, and increasing subspecialization and number of fellowship programs have all been cited as reasons why general surgery residents are not able to experience the level of operative autonomy they once did.
If I am not able to operate safely at the end of my general surgery training, I hope that my program would stop me from venturing out to perform independent operations on members of my community. Ideally, my program would be identifying deficiencies early and correcting them often so that I become as safe and competent a surgeon as I can be upon completion of my training. Although this idea of ensuring that surgical residency graduates are technically capable of performing procedures they will be doing in the future is intuitive, I would argue that the current surgical education system does not incentivize this and should be restructured accordingly.
I take no issue with the knowledge component (written and oral board exams) of the graduation requirements, but rather with the case requirements. Case logs provide minimal detail about operative autonomy, let alone competence. Additionally, there is significant variability in how case logs are completed — some residents aggressively log operations that they did not play a major role in while others only log the cases in which they performed the majority of the operation. As a result, one resident may perform an entire complex operation with minimal attending assistance and get the same credit as their colleague who barely performed a single step of the same operation independently. This volume-based system encourages quantity over quality and provides no guidelines as to how attendings should teach and/or assess the trainees’ competence.
This is where competency-based medical education (CBME) comes in. More and more, surgical educators are advocating for competency-based education as opposed to a volume-based model.2 This idea of proving a level of technical proficiency should be a welcome advancement to our field, embraced without hesitancy or fear. CBME has been piloted in surgery through initiatives such as Entrustable Professional Activities (EPAs) through the American Board of Surgery.3 However, such initiatives won’t take hold unless we as surgeons accept that a change is needed. Although we should not depart altogether from the current methods of surgical education, we need to realize their limitations and not be afraid to embrace new strategies of training and developing safe and effective surgeons.
- Cameron JL. William Stewart Halsted. Our surgical heritage. Ann Surg. 1997;225(5):445-458.
- Lindeman B, Sarosi GA. Competency-based resident education: The United States perspective. Surgery. 2020 May;167(5):777-781.
- Brasel KJ, Klingensmith ME, Englander R, Grambau M, Buyske J, Sarosi G, Minter R. Entrustable Professional Activities in General Surgery: Development and Implementation. J Surg Educ. 2019 Sep-Oct;76(5):1174-1186.