The development of surgical competency for trainees involves the melding of medical knowledge, technical skills, decision making, communication skills and leadership skills.¹ This developmental process is shaped by dynamic factors relating to the individual trainee, training program, technological innovation and societal expectations. Competency-based medical education (CBME) embraces this dynamic complexity by shifting the educational paradigm from a standardized training experience to one organized around predefined abilities, or competencies, of the individual trainee. Outcomes with the end in mind shape everything in the curriculum down to its structure, teaching mode, assessment, pace and completion metrics. Compared to the traditional training model, CBME is learner centered and self-paced rather than time based, where the pace is set by the educators. Completion of training in a CBME model occurs when a trainee demonstrates proficiency as opposed to merely completing a certain amount of time or required rotations. The paradigm shift to CBME seeks to better meet societal needs in the modern era of greater public accountability and exponential growth of medical science.²

In line with the international medical education community, North American urology training programs have incorporated various elements of CBME since the turn of the 21st century. The roots of CBME in urology are traced to the CanMEDS framework established by the Royal College of Physicians and Surgeons of Canada in 1996. ACGME (Accreditation Council for Graduate Medical Education) in the United States modeled their first iteration of CBME after CanMEDS with the launch of the 6 core competencies in 1999. The core competencies were then replaced with the Next GME Accreditation System in 2013. This system phased in specialty-specific, developmentally based achievements called Milestones that trainees are expected to demonstrate at established intervals as they progress through training. Under this system still in place today, Clinical Competency Committees are charged with the biannual assessment of each trainee on a batch of sub-competencies detailed in the Milestones.

The transition to CBME in urology has been met with concerns surrounding practicality and relevance. In particular, Milestones can be challenging to understand and are difficult to apply in everyday performance assessment. Meanwhile, other forces such as work hour restrictions, clinical productivity mandates, patient safety considerations and malpractice threats impact the ability of training programs to ensure every trainee graduates achieving proficiency in all competencies, especially in performing operative procedures. We already know that a large proportion of recent urology residency graduates do not feel comfortable performing core procedures such as percutaneous renal surgery, laparoscopic nephrectomy and robotic prostatectomy.³ Given the issues with the Milestones and concern over preparedness of graduates for unsupervised practice, the time is right for a better assessment system and more tools to properly implement CBME in daily clinical practice.

A new assessment system called Entrustable Professional Activities (EPAs) is on the horizon. EPAs represent authentic work activities that are executable, observable and measurable, and reflect multiple competencies.⁴ They capture the myriad entrustment decisions that occur daily in clinical settings with trainees present. In the surgical training context, general surgery is leading the adoption of EPAs in the United States. Lindeman et al describe the meticulous process of drafting EPAs that represent the full spectrum of work for a professional in the specialty.⁵ Opting to prioritize a pilot of the EPA conceptual framework first instead of defining the entirety of the specialty, a group of surgical educators defined 5 core tasks that represented the essence of general surgery and completed a 2-year EPA implementation pilot study at 28 training sites.⁵ The lessons learned from the pilot are currently informing the final preparations for the full complement launch of EPAs in general surgery in July 2023. Is urology up to the task of creating EPAs critical to our clinical practice?

Figure. The role of WBA in CBME.¹⁰

A new and improved assessment system such as EPAs for urology is wholly insufficient to fully implement CBME in training programs. If we think of competency like preparing a multi-course meal, then EPAs are the recipes for each course and workplace-based assessments (WBAs) are the kitchen utensils you use to prepare the recipes. WBAs are the tools designed to collect valid and reliable measurements of skills through direct observation. Over time, numerous measurements extracted from WBAs filled out by multiple evaluators are archived in a trainee’s portfolio. This portfolio of authentic assessments equips program leadership to make an informed decision on whether to progress or to remediate (see figure). In all, WBAs are the building blocks of proper CBME implementation.

Conveniently, leading surgical educators have already outlined best practices in translating direct observations of operative performance into meaningful performance metrics found in WBAs.⁶ These guidelines informed the development of evidence-based WBAs such as OpTrust (www.optrusteducation.com)⁷ and SIMPL (www.simpl.org).⁸ Many WBAs have substantial validity evidence and have proven to integrate feasibility into surgical training programs. All urology training programs should consider the adoption of WBAs.

The future of CBME in urology training is rife with opportunity. For example, a community of urology training programs using SIMPL and its robust data offerings is performing an educational quality improvement project in pursuit of a 100% proficiency standard for a set of operative procedures.⁹ Efforts like these showcase the power of CBME for the betterment of training and patient care.

Looking forward, urology has the chance to fully embrace CBME as it seeks to continue graduating urologists who serve the public providing safe and high-quality care. We clearly benefit from the lessons learned among our colleagues in other surgical specialties who have experimented with various forms of CBME in recent years. However, we should exercise caution in jumping headfirst onto the CBME bandwagon. Urological surgery training is unique in its commitment to train professionals in open surgery, minimally invasive surgery and endoscopic surgery. As a community, we must first collectively grasp what it means to be a proficient urologist and design an assessment system that captures this collective sentiment. This can only be done through effective engagement and collaboration with stakeholders at the American Board of Urology, Society of Academic Urologists, American Urological Association and ACGME.