The concept and trajectory of "operative competence" in surgical training.

T he terminal objective of surgical training is to produce competent surgeons capable of meeting the health care needs of our society. Recently , several accrediting medical bodies in North America proposed a framework of essential competencies required of all specialist physicians. The Royal College of Physicians and Surgeons of Canada's CanMEDS 2000 Project endorsed the following 7 core competencies: 1 medical ex-pert/clinical decision-maker, communicator , collaborator, manager, health advocate, scholar, and professional. Similarly, in 1999 in the United States, the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project adopted the following 6 competencies for all doctors: 2 patient care, medical knowledge , practice-based learning and improvement , interpersonal and communication skills, professionalism, and systems-based practice. Surgical training programs emphasize the achievement of both cogni-tive and technical competence. The cognitive ability of surgical trainees is clearly captured under competency domains including medical knowledge , clinical decision-maker and medical expert. 1,2 Cognitive competence requires mastery of a predefined body of knowledge. Traditionally, this is achieved through review of reference texts and medical journals, together with regular attendance at academic lectures, workshops, teaching rounds and conferences. Despite their importance to surgeons , motor skills or technical competence have historically been ill defined and consequently poorly assessed. 3 Technical competence is frequently not defined explicitly but hidden in definitions of core compe-tencies under nonspecific, subcate-gories including " medical expert — therapeutic skills for effective treatment " (CanMEDS) and " patient care — the performance of medical procedures " (ACGME). Technical competence is typically achieved in a graduated fashion through repeated exposure and hands-on practice as the surgical trainee progresses through residency. Despite increasing efforts to clearly define and assess the domains in which a surgeon must achieve competency, to date few surgical educators have studied precisely how such competencies are acquired over time. Here, we (a) introduce the concept of " trajectory " for compe-tency achievement, (b) speculate as to the trajectories of important com-petency domains in surgical training, and (c) propose a new and distinct competency domain — " operative competence " — and hypothesize as to the trajectory for its achievement. Cognitive competence The current standards for assessing cognitive knowledge include performance based Objective Structured Clinical Examination (OSCE) scores 4,5 and structured short-answer and multiple-choice questions. 6 On the basis of these standards, cognitive competence is typically acquired in an arithmetic fashion with a linear trajectory over the course of …