FAQs: Competency-Based Plastic Surgery Training Program

Current surgical residency programs are notable for a specific timeframe required for training, unique to each specialty. However, graduate medical education is on the brink of a paradigm shift in educating the next generation of physicians, with an emphasis on the skills gained rather that the time spent training. There is a growing body of evidence that competency-based, as opposed to time-based medical education, is this century’s Flexnerian revolution. By using a more developmental, integrated, and programmatic approach to curriculum and assessment, it is thought that we can educate our trainees more effectively and efficiently, provide much needed accountability to our patients and to the public, and establish a long-lasting model of self-motivated, lifelong learning.

Here at Pitt Plastic Surgery, we have embarked upon a longitudinal, integrated curricular and assessment innovation pilot to study different models of time-variable, competency-based plastic surgery resident education via a consortium of three plastic surgery programs. In essence, the milestones for educational progress are valued more than just the length of time of spent in the program. Of course, all residents much achieve the required competencies in order to graduate and there is already a precedent in US plastic surgery programs for residents to spend extra time in a program if skills need to be further developed. What is new in the CBPST program is that a resident who reaches specific milestones ahead of schedule will be allowed to graduate at the end of 5 clinical years, rather than 6.

The Consortium for Competency-Based Plastic Surgery Training (CCBPST) consists of three programs, specifically chosen based upon their willingness to innovate in surgical education and to embrace culture change. They were all early adopters of the integrated training format, some being amongst the first in the US to be accredited as such and to recognize its benefits. Their faculty includes leaders in organized plastic surgery with regard to education, each with multiple faculty members active in American Council of Educators in Plastic Surgery, having advanced degrees in education, and with solid track records of educational research. Two programs, the University of Pittsburgh and Baylor Scott & White initiated the CBPST program in 2018-19. Johns Hopkins University joined them in 2019-20.

Plastic surgery is uniquely positioned to implement a competency-based model.  The current U.S. integrated residency is six years long. When the integrated curriculum was first implemented, however, the training lasted five years, and the graduates of the programs had ABPS written exam pass rates and reputations as practitioners similar to those residents finishing six-year integrated programs.  There was little hard data to support the decision to require integrated programs to last six years as opposed to five. At the same time, the Canadian training system is currently a five-year, time-based curriculum that the ABPS recognizes as providing adequate training to be eligible for certification. In other words, plastic surgery has a history of being able to produce competent plastic surgeons in five years, therefore, if plastic surgery implements a competency-based model, it is possible that some residents may be able to demonstrate competency in less than six years and those residents trained in less than six years are likely to be safe and competent surgeons.

The CBPST program represents an application to the ACGME Advancing Innovation in Residency Education (AIRE) pilot program in an effort to fulfill the aims of 1) enabling the exploration of novel approaches and pathways in GME, and 2) enhancing the attainment of educational and clinical outcomes through innovative structure and processes in resident and fellowship education. The competency-based program has consequently obtained approval via the American Board of Plastic Surgery (ABPS) and the Plastic Surgery Review Committee (PS-RC), in order to train, advance, and graduate residents through the innovative program and to subsequently achieve board certification.

Since the 2018-19 academic year, Integrated residents in their R1 year began participating in the competency-based program. While Integrated residents in prior years of training and Independent residents will not formally participate in the CBPST program, the spectrum of assessment, feedback, and evaluation tools utilized as part of the competency-program will be employed across the entire residency program.

In one sense, the CBPST program represents a paradigm change in graduate medical education, by shifting the focus of learning from time to that of competency. It recognizes the fact that individuals have differing levels of knowledge, skills, and attitudes, and therefore intrinsically learn at different rates. In addition to changes in the curriculum, we are instituting a battery of new assessment tools (e.g., Milestone Modular Examinations, SIMPL app for intraoperative assessment) in order to better assess for competency and to provide improved formative and summative feedback. In another sense, we are not seeking to eliminate the old model, but to improve upon it by enhancing the role of competency assessment and flexibility, and allowing the exceptional resident to graduate sooner, while at the same time accommodating the resident who needs more time to proceed along the currently available paths. By the proposed assessment methods, programs will be able to identify struggling residents sooner in order to allow for more individualized education and additionally avoid the stigma of remediation.

Both residents and programs need to be able to plan for the future, so a set of benchmarks have been established that indicate when a resident’s current level of competency and learning trajectory suggest that it is highly likely he or she will be able to finish the program at an accelerated rate. Key assessments, including Milestones, Plastic Surgery Operative Logs, and the global assessment by the Clinical Competency Committee, will be utilized beginning in the second year of Integrated residency and progressing on, with critical benchmark assessments made at 2 years and at 1 year prior to anticipated completion of the program.

Of note, no resident will finish the program until the resident’s self-assessment and the faculty’s assessment of competency are aligned. Therefore a resident may elect to stay within the residency, despite being assessed as competent to graduate by the program.

With the above mentioned benchmark assessments, we will be able to anticipate in advance which and when residents in the CBPST program will be expected to be graduating and therefore be able to plan appropriately for the respective fellowship process. This is of note very much like it is done currently in the time-based system, but only potentially at an earlier timeframe.

As to how fellowship directors/faculty may view a competency-based resident who is completing their residency at an accelerated rate, we can not directly control for this, but believe that any such resident would be viewed positively in regards to their ability and self-motivation. Additionally, member programs in the competency-based consortium have positions that cover the spectrum of fellowship training.