Competency-based Surgical Training and Entrusted Professional Activities – Perfect Match or a Procrustean Bed?

The dictum of “see one, do one, teach one,” or the apprenticeship model, was introduced by William Halstead in the end of the 19th century. Since then, this has prevailed as the preferred model in surgical training. It has allowed trainees to learn and practice simultaneously, with a gradual increase in autonomy. Sir William Osler described it as the “natural method of teaching” based on longitudinal patient experience.1 Despite this centenary impact, changes to profession and society have altered medical education and surgical training in the last decades. The medical knowledge base has increased exponentially, the scientific half-life of medical “truths” has decreased, and the focus on patient safety and quality of care has become center to health care providers, stakeholders, and the public. Work-hour regulations have influenced training programs. New technology, development of surgical tools and targeted drugs have led to changes in management of diseases previously untreatable. In sum, alterations in thinking, teaching, and education have had an unprecedented impact on surgical practice – and surgical training has gone from counting procedures (“how many have you done?”) to evaluation of competence (“what can you do independently, and how well?”). This new mindset is frequently described as the competency-based model. The model is currently present in several forms; colleges, societies, or regional regulators are re-shaping the structure of a surgeon's training path. The overarching goal is to obtain training that will provide surgeons with knowledge and skills in their future fields of practice. However altruistic the idea, this enforced skillset is difficult to accomplish as a “one-size-fits-all” program for all surgeons and across disciplines. THE PROCRUSTEAN BED Greek mythology tells the tale of an evil innkeeper called Procrustes. Procrustes was said to have a magic bed that would exactly match any guest who would lay upon it. However, there was never really a “perfect bed,” as Procrustes secretly possessed 2 beds to ensure fitting being necessary. His guests were; therefore, unavoidably “customized” by either stretching (if they were too small for the bed) or by cutting off their limbs (if too long for the bed) so they would fit the bed. In both cases, the guest would die. Metaphorically, the Procrustean bed has come to represent a forced conformity – a “one-size-fits-all” approach. This is applicable in traditional surgical training, with the focus upon time spent and number of procedures performed2 – assuming that exposure to patients and experience over a fixed amount of time is sufficient to ensure training of competent surgeons.1 FROM NOVICE TO EXPERT – MANY WAYS LEAD TO ROME? Novice learners focus on understanding the activity and concentrate on avoiding mistakes. With increasing experience, performance seems smoother and the learner can perform at an acceptable level. Eventually, the skills become automated and one reaches a stable plateau phase where no further improvement can be expected to occur automatically. An expert surgeon can be defined as someone who is able to perform at virtually any time with relatively limited preparation.3 However, nobody becomes an expert without experience, but experience does not invariably lead to expertise. In some measurable medical activities (ie, the accuracy of diagnosis of heart sounds) there has proven to be no demonstrable improvement in performance as a function of years of experience after completed training.3 There are strong indications that the key to improving performance is continued experience, coupled with deliberate practice. Deliberate practice involves repeated practice on well-defined tasks, and immediate feedback on performance.2 As an example, laparoscopic appendectomies have proven to be safe as a teaching procedure, and outcome is not inferior when the procedure is performed by a resident.4 However, to maximize learning outcome and facilitate deliberate practice, each appendectomy should be followed by feedback and reflection on action, and the possibility for training on specific tasks before next surgery. Aspiring experts must actively use deliberate practice to avoid the arrested development associated with automaticity. Improvement requires full concentration – and often problem-solving and better methods of solving the task. Deliberate practice is thereby of great importance to surgeons – both in the striving for expertise, but also due to the demand for lifelong learning. COMPETENCE AND GRADED AUTONOMY RESPONSIBILITY Considering that up to half of all major complications from surgical procedures are potentially avoidable, it is in everyone's best interest to develop evaluation methods to ensure that the current practice is actually making surgeons competent in technical and nontechnical skills.5 The introduction of “entrustable professional activities” (EPAs) has offered a tool for assessing competence that enables educators to translate the competencies into observable aspects.6 An EPA is defined as a unit of activity undertaken which the trainee could be entrusted to complete7 and is highly applicable in deeming trainees competent for selected tasks. EPAs should therefore play an increasingly important role in benchmarking, certification, and accreditation – also across countries and even across continents. EPAs could attend to all aspects of core competencies. For example, being competent in treating acute appendicitis would not simply mean ability to technically perform an appendectomy. Rather, and just as important, it would include being able to diagnose patients based on symptoms and presentation, choosing the right diagnostic aids for the specific demographic population, decide when surgery is indicated (and when it is not), and being able to take care of the patients both before, during and after surgery. Only when fully mastering the ability of all aspects, a trainee can be considered competent, that is “have the ability to successfully apply professional knowledge, skills, and attitudes to new situations and to familiar tasks.”5 Importantly, this would also include acknowledgement and acceptance of the resident's own limitations, including knowing when and who to ask for help or advice. Thus, we argue to include both knowledge, attitude, and procedural skills when making an EPA decision, that is, making the decision whether or not a trainee can be entrusted to autonomy in a specified task (Fig. 1).FIGURE 1: EPA in competency-based surgical education. Deliberate training before assessing competence in specified EPAs. Testing, that is, assessing competence, can be done either as structural or as ad hoc testing. EPA denotes entrusted professional activity; EPA scoring from 1 to 5, where 1 = unable to perform, 2 = safe to perform under supervision, 3 = safe to perform with available supervision, 4 = safe to perform without supervision, and 5 = safe to supervise others. EPA decision 1–3 must lead to further deliberate practice before renewed assessment. EPA indicates entrustable professional activities.SURGEON EDUCATORS IN THE NEW COMPETENCY-DRIVEN MODEL Surgeons may possess numerous roles in addition to being clinicians; administrators, leaders, researchers - and educators. The traditional assumption that clinical expertise automatically translates into teaching expertise – as in “see one, do one, teach one” – is increasingly understood as misplaced. Rather than trusting an innate ability to teach, this skillset needs to be harnessed, matured, and implemented by a structured and intended program for surgeon educators. Increased acknowledgment on the lack of formal pedagogic and didactic training of surgeons has led to numerous “train-the-trainer”-initiatives, and revealed a much needed and timely focus on education as a core role for surgeons. The introduction of “Master educators” recognition by the American College of Surgeons, is but one formal recognition of the importance of surgeon educators. Education should preferably evolve into a domain within surgical practice comparable to manager roles or clinical and basic research positions to enhance the value of life-long education and training in surgery. Further, although beyond the scope of this article, incorporation of novel technologies including machine learning and artificial intelligence will enhance modes of feedback and evaluation during training to objectively gauge competency and performance. Also, agreed consensus on core points of competency may reduce variation between programs and countries and allow for better comparison between regions. THREATS TO TRANSFERABILITY Studies show that surgical exposure and procedure experience is highly variable across countries.8 At the same time, standardization of curricula, defining core set of procedures, and enforcing basic competencies have never been more needed. The lack of a surgical workforce in parts of the world,9 suggests a need to arrive at common standards that ensure competencies in a core set of procedures that would be understood and transferable across regions. Currently, training programs are operating in isolation and not much in agreement. Even across several comparable systems – and despite the recognized need – there is no universal agreement on how to best train a modern surgeon. Moreover, there is not even an agreement on how to best prepare the surgeon educators to train the new generation of surgeons. It thus begs the question; in an attempt to make a best match for all, are we actually at risk for trading one Procrustean bed for another? Despite the intentions on moving towards competency-based educational models, most countries still demand a fixed amount of time spend in surgical training and a fixed number of procedures performed to be certified as surgeons. Notably, there is growing concern that regulations, patient safety issues, and public opinions have led to decreased responsibility and autonomy among residents.6 The number of procedures performed may for a vast majority consist of assistant performance, or more frequently, with a consultant surgeon present during the procedure. This might in turn lead to surgeons being unable to perform independently after completed training. The increasing role of fellowship training beyond general surgery is proof that “see one, do one, teach one” is not enough, nor has current practice in surgical education adequately caught up with proficient solutions for building competence during general surgery training. Lectures, passive watching of procedures and accumulated hours of passive professional experience have proven ineffective as learning methods10 and should be replaced by a more active approach. Observing the performance and behavior of a trainer as a role model, reflecting in and on action, and feedback on performance are important education principles to be considered in teaching and learning in surgical clinical settings.11 CONCLUSIONS Moving from procedure numbers to competency-based training is rightfully needed in surgical education. A graded transfer of responsibility and independence should follow logical, measurable, and stepwise paths to achieve competence. Highly effective and deliberate training both in and outside the operating room and the introduction of EPAs should play an important role in the training of future surgeons. The goal is to regain surgical residents’ access to a graduated responsibility during training and increased autonomy before independent practice – a legacy from Halsted that should still be considered fundamental in surgical training.