Competency-Based vs. Time-Based Education in Neurosurgery

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

<WRAP box 100% center round info> This article compares competency-based and time-based education in neurosurgery, with special emphasis on the German model as a case study of CBE implementation. </WRAP>

Modern neurosurgical training is evolving from traditional time-based models to competency-based training. This article explores the principles, strengths, and limitations of both approaches, using the Germany system as a model for competency-based neurosurgical training.

Neurosurgical education has long relied on fixed durations and structured rotations. However, modern demands are steering programs toward competency-based education (CBE). Germany stands out in Europe for its structured yet flexible implementation of this model.

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• Fixed duration: Typically 5–7 years of residency.
• Structured rotations: Tumors, spine, pediatrics, etc.
• No Board exam at the end of training.
• Linear progression, regardless of individual pace.

<WRAP half column> ✅ Strengths

• Simple and standardized
• Predictable for staffing and scheduling
• Encourages peer relationships

</WRAP> <WRAP half column> ⚠️ Weaknesses

• Not tailored to learning speed
• Risks passive progression
• Emphasis on volume, not competence

</WRAP>

• Milestone-driven learning
• Flexible timelines
• Use of Entrustable Professional Activities (EPAs)
• Frequent formative assessments
• Strong focus on professionalism and clinical reasoning

• Governed by State Chambers of Physicians (Ärztekammern).
• Training based on Weiterbildungsordnung (postgraduate regulations).
• Logbooks are used to document actual competencies, not just time.
• Requirement for direct supervisor validation of core surgical skills.
• Board exam focuses on clinical decision-making, not rote knowledge.
• Flexible length: Completion depends on competency achievement.

<WRAP tip> Germany’s shift to CBE encourages autonomy, adaptability, and personalized progression. </WRAP>

<WRAP alert> Transitioning to CBE requires: </WRAP>

1. Faculty training in assessment techniques
2. Creation of valid tools for competency evaluation
3. Institutional capacity for individualized progression
4. National alignment and certification standards

CBE offers a promising alternative to traditional models, as seen in the German experience. It emphasizes mastery over time, allows individualized learning paths, and aligns better with the complexities of modern neurosurgical care. Future training models should consider integrating CBE elements to ensure high-quality, adaptive, and responsible neurosurgical education.

<WRAP lo red round 90%> Spain follows a strict time-based model for neurosurgical training, with limited competency verification at the end of the residency. </WRAP>

• Fixed duration: 5 years of residency, regardless of trainee performance.
• Structured rotations: Tumors, spine, pediatrics, skull base, etc., but lacking national standardization in content or duration.
• No national final board exam: There is no centralized, objective assessment of knowledge or surgical skills at the end of training.
• Linear progression: Advancement is determined by residency year, not actual competence.

1. Training inequality across hospitals: Not all centers offer balanced exposure to all subspecialties.
2. Risk of graduating underprepared residents: Without final objective evaluations or defined milestones.
3. Lack of structured feedback: Assessments are informal and highly dependent on individual tutors.
4. Demotivation for high-performing residents: No option to progress faster, even if exceeding expectations.
5. Limited international recognition: The absence of final certification or competency exams hinders global mobility.

<WRAP box round tip> 👉 In contrast, models like the German competency-based approach promote individual responsibility, learning autonomy, and ongoing real-world evaluation. </WRAP>

Neurosurgery is among the most demanding medical specialties, requiring not only technical excellence but deep clinical judgment, resilience, and lifelong learning. Yet, the Spanish system for training neurosurgeons remains entrenched in an obsolete, time-based model that fails to guarantee competency, consistency, or accountability. While other nations evolve toward rigorous competency-based frameworks, Spain’s system lags dangerously behind, raising ethical, clinical, and professional concerns.

The foundation of neurosurgical training in Spain is a fixed-duration residency: five years, structured into predefined rotations (tumors, spine, vascular, pediatrics, etc.), typically without formal documentation of competency milestones. Progression is automatic, dictated by calendar time rather than demonstrated skill or readiness. There is no national final board exam. No procedural benchmarks. No standardized assessments of intraoperative decision-making or surgical autonomy.

Residents may complete their training without ever being formally evaluated on their capacity to independently perform critical neurosurgical procedures. The assumption that time served equates to competence is both scientifically unfounded and ethically indefensible.

Spain lacks a centralized national body that enforces minimum educational standards or audits training quality across hospitals. Each training center operates independently, with wide variability in surgical volume, faculty expertise, and subspecialty exposure. While some residents receive robust, well-supervised training, others operate in under-resourced departments where their learning is opportunistic and inconsistent.

There is no national logbook of surgical cases, no uniform curriculum, and no system to ensure that residents are exposed to the full spectrum of neurosurgical pathology. This results in profound inequality of training—one of the most corrosive features of the current model.

Perhaps most alarming is the fact that there is no national regulation governing how many hospitals may train neurosurgeons. The creation of new residency positions often depends solely on a department chief's request, without rigorous external review of case load, educational capacity, or subspecialty availability.

This leads to the accreditation of training programs in low-volume hospitals, some of which lack even the most basic infrastructure for neurosurgical education. The motivations behind these new positions are often more administrative or labor-related than educational. In effect, residency becomes a mechanism for staffing, not learning.

Despite widespread awareness of these deficiencies among neurosurgeons and residents, few speak out. A culture of complacency, combined with fear of professional retaliation, preserves the status quo. Institutional inertia and bureaucratic complexity further block reform. There is no national forum for resident advocacy, no anonymous reporting system, and no incentives for transparency or innovation.

The risks of this training model are not theoretical—they are real. Undertrained neurosurgeons may be placed in high-responsibility roles without the skills or confidence to manage them. Patients may suffer the consequences of surgical inexperience, poor decision-making, or inadequate supervision. Meanwhile, capable residents are stifled by rigid structures that reward time over talent.

Internationally, Spain's standing in surgical education is eroding. Spanish-trained neurosurgeons often struggle to demonstrate equivalence when applying abroad. Conversely, foreign-trained specialists are met with bureaucratic resistance when attempting to integrate into the Spanish system, no matter how superior their background.

Spain's neurosurgical training system does not need minor adjustments—it needs comprehensive reform. Essential measures include:

• Establishing a national competency-based curriculum with defined milestones and entrustable professional activities (EPAs).
• Creating and enforcing a national surgical logbook with procedural minimums and case audits.
• Requiring a standardized, high-stakes national final board exam.
• Auditing and accrediting training centers based on objective quality indicators.
• Freezing the expansion of new training centers until minimum volume and infrastructure standards are assured.
• Empowering residents through formal feedback systems, anonymous reporting, and national representation.

The current model of neurosurgical training in Spain is obsolete, fragmented, and dangerously permissive. It fails to protect patients, demotivates talent, and isolates Spain from international progress in surgical education. Radical change is no longer a matter of professional ambition—it is an ethical obligation.

Until this transformation occurs, every graduating neurosurgeon remains a product of a system that prioritizes duration over competence, bureaucracy over quality, and tradition over truth.