Competency-based education in neurosurgery
Difference Between Time-Based and Competency-Based Training
| Feature | Time-Based Training | Competency-Based Training |
|---|---|---|
| Definition | Training progresses based on fixed durations (e.g., months or years). | Training progresses based on demonstrated skills and knowledge. |
| Progress Criteria | Time spent in the program. | Mastery of specific competencies. |
| Learning Pace | Fixed for all learners. | Flexible; personalized to each learner. |
| Curriculum | Standardized for all learners. | Individualized based on learning needs. |
| Assessment Focus | Attendance and task completion. | Skill demonstration and outcome-based. |
| Advancement | Scheduled, often with cohorts. | As soon as competencies are demonstrated. |
| Common In | Traditional education systems. | Modern training frameworks (e.g., medical, vocational). |
| Best When | Uniform exposure is the goal. | Mastery and performance are the priority. |
Example:
- *Time-Based:* A residency lasts 5 years regardless of individual progress.
- *Competency-Based:* A resident advances based on skill, not seniority.
Competency-Based Education (CBE) in Neurosurgery is an educational model that focuses on the acquisition and demonstration of specific competencies—knowledge, skills, attitudes, and behaviors—required for safe, effective, and independent neurosurgical practice. Unlike time-based training, where progression is determined by duration, CBE emphasizes outcomes and milestones to assess readiness for practice.
🔍 Core Principles of CBE in Neurosurgery
Outcome-Driven: Focus on what a neurosurgeon must be able to do at the end of training.
Individualized Progression: Learners advance upon demonstration of competence, not based on time spent.
Transparent Expectations: Defined milestones, Entrustable Professional Activities (EPAs), and competencies.
Frequent Assessment: Emphasis on formative and summative feedback, often with workplace-based assessments (WBAs).
Faculty Development: Requires trained evaluators to assess and mentor trainees consistently.
🧠 Key Components
Competency Domains: Often aligned with frameworks like CanMEDS or ACGME:
Medical Knowledge
Patient Care
Interpersonal & Communication Skills
Systems-Based Practice
Practice-Based Learning and Improvement
Milestones: Developmental stages within each competency (e.g., novice to expert).
EPAs (Entrustable Professional Activities): Tasks a neurosurgeon must perform independently (e.g., “Perform a craniotomy for brain tumor resection”).
🛠️ Implementation Strategies
Curriculum Mapping: Align learning experiences with desired outcomes.
Assessment Tools:
Direct Observation
Mini-CEX (Clinical Evaluation Exercise)
DOPS (Direct Observation of Procedural Skills)
360° Feedback
Simulation-based assessments
Learning Portfolios: Document and reflect on competency development.
Mentorship & Coaching: Longitudinal guidance for progression.
📊 Benefits
Promotes learner-centered education
Enhances accountability and transparency
Supports early identification of struggling learners
Better prepares residents for independent practice
⚠️ Challenges
Requires cultural change in traditional training programs
Demands significant faculty time and engagement
Need for valid and reliable assessment tools
Risk of overburdening trainees and educators with documentation
📚 Example Initiatives
Royal College of Physicians and Surgeons of Canada – Competence by Design
U.S. ACGME Milestone Project
European Board of Neurological Surgery (EBNS) incorporating EPAs
see Neurosurgical Resident Training.
Competency-based medical education is well established, yet methods to evaluate and document the acquisition of surgical skills remain underdeveloped. Sorenson et al. describe a novel web-based application for competency-based surgical education at a single neurosurgical department over 3 years.
They used a web-based application to track procedural and cognitive skills acquisition for neurosurgical residents. This process included self-assessment, resident peer evaluations, evaluations from supervising attending physicians, and blinded video reviews. Direct observation by faculty and video recordings were used to evaluate surgical skills. Cases were subdivided into component skills, which were evaluated using a 5-point scale. The learning curve for each skill was continuously updated and compared with expectations. Progress was reviewed at a monthly surgical skills conference that involved discussion and analysis of recorded surgical performances.
During an escalating 3-year pilot from 2019 to 2022, a total of 1078 cases in 39 categories were accrued by 17 resident physicians with 10 neurosurgical faculty who participated as evaluators. A total of 16 251 skill performances in 110 categories were evaluated. The most evaluated skills were those that were common to several types of procedures, such as positioning, hemostasis, and wound closure. The concordance between attending evaluations and resident self-evaluations was 76%, with residents underestimating their performance in 17% of evaluations and overestimating in 7%.
They developed a method for evaluating and tracking surgical resident skill performance with an application that provides timely and actionable feedback. The data collected from this system could allow more accurate assessments of surgical skills and deeper insights into factors influencing surgical skill acquisition 1)
Competency-based training refers to a learning model where students must demonstrate the required level of knowledge and skill (competency) on a task prior to advancing to the next task.
Budden et al. assessed the case volume and self-perceived competence of current mandatory skills in peripheral nerve surgery.
Design: Cross-sectional survey based study examining case volume and self-reported competence in peripheral nerve surgery.
Setting: Canadian Neurosurgery and Plastic Surgery accredited residency programs PARTICIPANTS: All Canadian Neurosurgery and Plastic Surgery senior trainees (PGY 3+) invited to participate RESULTS: Much variability exists in both exposure to cases and perceived senior resident competence for both plastic and neurosurgery residents. Confidence in surgical ability as perceived competency is lower in trainees for more advanced peripheral nerve procedures. Self- reported confidence increased with post-graduate experience.
Conclusions: Overall, the findings in this study highlight the importance of increasing surgical experience in complex peripheral nerve surgery among surgical residents 2).
A Competency-based educational approach focuses on developing and assessing specific competencies or skills in students. Rather than solely emphasizing the acquisition of knowledge, competence-based learning aims to ensure that students can apply what they have learned in real-world contexts. Here are some key characteristics and benefits of competence-based learning:
Emphasis on skills: Competence-based learning places a strong emphasis on developing practical skills and abilities. It focuses on what students can do rather than just what they know.
Clear learning outcomes: This approach defines specific learning outcomes or competencies that students are expected to achieve. These outcomes are often described in terms of observable and measurable behaviors or skills.
Personalized learning: Competence-based learning recognizes that students have different starting points and learning paces. It allows for personalized learning pathways and adapts to individual student needs, allowing them to progress at their own pace.
Authentic assessment: Competence-based learning utilizes authentic assessments that evaluate students' ability to apply their knowledge and skills in real-world situations. These assessments often involve performance tasks, projects, portfolios, and simulations.
Flexibility and modular structure: Competence-based learning is often organized into modular units or competencies, allowing students to progress based on their demonstrated mastery of each competency. It offers flexibility in terms of pacing, allowing students to move ahead when they have achieved proficiency.
Practical relevance: Competence-based learning aims to connect classroom learning to real-world applications. It focuses on developing skills that are directly relevant to future careers or practical contexts.
Lifelong learning focus: Competence-based learning encourages lifelong learning by fostering skills that are transferable and adaptable to different contexts. It prepares students for continuous learning and skill development throughout their lives.
Competence-based learning is often seen as an alternative or complement to traditional content-based education. It promotes a more student-centered and practical approach to learning, ensuring that students acquire the necessary skills and competencies to succeed in their chosen fields or professions.