Implementation of a Competency-Based Training Program in Pediatric Surgery: A Pilot Study

Current surgical trainees experience less autonomy in their training than prior generations. Intentionally integrating graduated autonomy into the educational development of fellows would enhance trainee competence while providing the safety net of fellowship programming. The objective of this study was to pilot a competency-based training (CBT) approach for pediatric surgery fellowship programs.

A CBT approach was developed at a single pediatric surgery fellowship program. Three goals were identified for the development of the CBT structure: 1) demonstrate flexibility for trainees to gain knowledge and skills at individualized paces, 2) readily identify and address knowledge gaps, and 3) facilitate increased autonomy for fellows while in training, in areas where competence has been successfully assessed. The CBT program consisted of five components: operative evaluations, a communication assessment tool (CAT), entrustable professional activities (EPAs), oral exams, and video reviews. Once a fellow completed the minimum requirements of each component, they proceeded to the final review at the clinical competency committee (CCC) meeting. For this pilot, we tracked the changes that were made to the program over the first few years as well as progression of the first six fellows and their participation in the various components.

Between 2017 and 2023, six pediatric surgery fellows were evaluated by fourteen pediatric surgery faculty. Three fellows progressed through the pilot program with three procedures (Laparoscopic Appendectomy, Laparoscopic Inguinal Hernia Repair, and Laparoscopic Pyloromyotomy), while the other three fellows progressed through the program with these three initial and two additional procedures (Laparoscopic Gastrostomy Tube Placement and Open Malrotation Repair). The median number of each component completed was: 5 CATs, 101 operative evaluations, 4 oral exams, and 3 video reviews. Fellows achieved competency for 1-4 procedures. From semi-structured interviews, fellows appeared overall satisfied with their experience of the CBT program, stating that these additional sets of tasks and requirements were a helpful thought exercise, provided an extra layer of structure to the curriculum, created a culture of independence and autonomy, and gave added purpose to the first year of training. The principal strength of the program was the structured format leading to graduated autonomy. All fellows reported feeling very prepared to move into a faculty role following graduation from fellowship training.

Competency-based training may allow for identification of specific gaps in knowledge, skills or abilities and support progressive autonomy among trainees prior to fellowship graduation. Generating further validity evidence and engaging in implementation research are necessary for quality improvement and dissemination of the program.