A Competency-Based Approach to Functional Neurosurgery Training: Insights From the Surgical Autonomy Program

The Accreditation Council for Graduate Medical Education (ACGME) relies on case minimums as a standard competency indicator, set by expert opinion rather than individual resident performance. We used the Surgical Autonomy Program, a validated method of competency-based resident evaluation, to track autonomy progression across residency and compare the reported number of cases it took residents to reach autonomy with the case minimums set by the ACGME.

Data from neurosurgery residents across 14 institutions on five functional procedures (deep brain stimulation [DBS], internal pulse generator implantation [IPG], percutaneous spinal cord stimulator placement [SCS], epilepsy vagal nerve stimulation [VNS], and epilepsy stereo electroencephalography [SEEG]) were analyzed. Surgical autonomy was measured using a four-point Teach, Advise, Guide, Solo scale (TAGS), a modified version of the Zwisch scale in which "T" represents the lowest and "S" the highest level of independence. These scores were tracked over time to create learning curves delineating autonomy progression. The number of cases required to achieve competency for the first and second time were determined and compared with ACGME case minimums. Results were analyzed with descriptive statistics.

On average, residents showed advanced competency, defined as scoring among the top two TAGS scores, approximately postgraduate year (PGY) 3 for DBS, VNS, and SCS cases, and approximately PGY-2 for IPG and SEEG cases. Median case volumes for achieving competency (first time, second time) were DBS 16, 16 (ACGME minimum [min.] ten); IPG 12, 13 (min. ten); SCS 14, 16 (min. ten); VNS 6, 12 (min. ten); SEEG five, seven (min. ten). Individual variance in competency levels and rate of progression was observed.

Although DBS, IPG, and SCS procedures required more cases to reach competency than ACGME standards suggest, VNS and SEEG required fewer, indicating that case complexity and learning curves vary significantly across subspecialties. A competency-based approach, recognizing individual progression, could enhance surgical training efficacy and improve assessment of surgical autonomy on graduation. Future studies should explore the long-term outcomes of competency-based training to validate these findings further.