Competency-based Surgical Education Research Articles

Case Curve: A Novel Web-Based Platform and Mobile Phone Application to Evaluate Surgical Competence in Graduate Medical Education.

Competency-based medical education is well established, yet methods to evaluate and document acquisition of surgical skill remain underdeveloped. We describe a novel web-based application for competency-based surgical education at a single neurosurgical department over a 3-year period. We used a web-based application to track procedural and cognitive skills acquisition for neurosurgical residents. This process included self-assessment, resident peer evaluations, evaluations from supervising attending physicians, and blinded video reviews. Direct observation by faculty and video recordings were used to evaluate surgical skill. Cases were subdivided into component skills, which were evaluated using a 5-point scale. The learning curve for each skill was continuously updated and compared with expectations. Progress was reviewed at a monthly surgical skills conference that involved discussion and analysis of recorded surgical performances. During an escalating 3-year pilot from 2019 to 2022, a total of 1078 cases in 39 categories were accrued by 17 resident physicians with 10 neurosurgical faculty who participated as evaluators. A total of 16 251 skill performances in 110 categories were evaluated. The most evaluated skills were those that were common to several types of procedures, such as positioning, hemostasis, and wound closure. The concordance between attending evaluations and resident self-evaluations was 76%, with residents underestimating their performance in 17% of evaluations and overestimating in 7%. We developed a method for evaluating and tracking surgical resident skill performance with an application that provides timely and actionable feedback. The data collected from this system could allow more accurate assessments of surgical skills and deeper insights into factors influencing surgical skill acquisition.

Predicting Resident Competence for Otolaryngology Key Indicator Procedures.

Competency-based surgical education requires practical assessments and meaningful benchmarks. In otolaryngology, key indicator procedure (KIP) minima are indicators of surgical exposure during training, yet it remains unknown how many times trainees must be evaluated on KIPs to ensure operative competence. Herein, we used Bayesian mixed effects models to compute predicted performance expectations for KIPs. From November 2017 to September 2021, a smartphone application (SIMPL OR) was used by attendings at five otolaryngology training programs to rate resident operative performance after each case on a five-level scale. Bayesian mixed effects models were used to estimate the probability that postgraduate year (PGY) 3, 4, or 5 trainees would earn a "practice-ready" (PR) rating on a subsequent evaluation based on their previously earned PR ratings for each KIP. Probabilities of earning a subsequent PR rating were examined for interpretability, and cross-validation was used to assess predictive validity. A total of 842 assessments of KIPs were submitted by 72 attendings for 92 residents PGY 2-5. The predictive model had an average Area Under the Receiver Operating Curve of 0.77. The number of prior PR ratings that senior residents needed to attain a 95% probability of earning a PR rating on a subsequent evaluation was estimated for each KIP. For example, for mastoidectomies, PGY4 residents needed to earn 10 PR ratings whereas PGY5 residents needed 4 PR ratings on average to have a 95% probability of attaining a PR rating on a subsequent evaluation. Predictive modeling can inform assessment benchmarks for competency-based surgical education. NA Laryngoscope, 133:3341-3345, 2023.

Charting the future of competency-based surgical education: a systematic review of cumulative sum

PurposeThere is broad interest in the education community to shift surgical training from volume-based to competency-based benchmarks. Cumulative sum (CUSUM) is a method for tracking performance and identifying trainee proficiency that may prove useful in facilitating competency-based training. The purpose of this study is to review the CUSUM surgical education literature to: (1) provide an overview of CUSUM implementation, and (2) examine the capacity of CUSUM to identify learning variations and proficiency gaps. MethodsA systematic search of the PubMed, Embase, and Google Scholar databases was performed to identify studies that used CUSUM to track and evaluate learning and proficiency within general surgery and surgical subspecialties.ResultsForty-two articles published between 1995 and 2021 met the review criteria. There was an increase in the annual number of CUSUM-related publications over time. Most articles were related to general surgery. Both in-vivo and simulation tasks were well-represented. 71% of studies identified learning variability among participants, and 43% reported at least one participant who failed to achieve proficiency during the study period.ConclusionsCumulative sum (CUSUM) charts can be used to identify learning variability, proficiency development, and the need for intervention at all surgery training levels. Formal implementation of this tracking method can contribute to competency-based surgical curricula.

Step, Error, and Event Frameworks in Endovascular Aortic Repair

Objective: Competency-based surgical education requires detailed and actionable feedback to ensure adequate and efficient skill development. Comprehensive operative capture systems such as the Operating Room Black Box (ORBB; Surgical Safety Technologies, Inc), which continuously records and synchronizes multiple sources of intraoperative data, have recently been integrated into hybrid rooms to provide targeted feedback to endovascular teams. The objective of this study is to develop step, error, and event frameworks to evaluate technical performance in elective endovascular aortic repair (EVAR) comprehensively captured by the ORBB (Surgical Safety Technologies, Inc; Toronto, Canada). Methods: This study is based upon a modified Delphi consensus process to create evaluation frameworks for steps, errors, and events in EVAR. International experts from Vascular Surgery and Interventional Radiology were identified, based on their records of publications and invited presentations, or serving on relevant journal editorial boards. In an initial open-ended survey round, experts were asked to volunteer a comprehensive list of steps, errors, and events for a standard EVAR of an infrarenal aorto-iliac aneurysm (AAA). In subsequent survey rounds, the identified items were presented to the expert panel to rate on a 5-point Likert scale. Delphi survey rounds were repeated until the process reached consensus with a predefined agreement threshold (Cronbach α>0.7). The final frameworks were constructed with items achieving an agreement (responses of 4 or 5) from greater than 70% of experts. Results: Of 98 invited proceduralists, 38 formed the expert consensus panel (39%), consisting of 29 vascular surgeons and 9 interventional radiologists, with 34% from North America and 66% from Europe. Consensus criteria were met following the third round of the Delphi consensus process (Cronbach α=0.82–0.93). There were 15, 32, and 25 items in the error, step, and event frameworks, respectively (within-item agreement=74%–100%). Conclusion: A detailed evaluation tool for the procedural steps, errors, and events in infrarenal EVAR was developed. This tool will be validated on recorded procedures in future work: It may focus skill development on common errors and hazardous steps. This tool might be used to provide high-quality feedback on technical performance of trainees and experienced surgeons alike, thus promoting surgical mastery.

TrustEd: A Tool for Developing Intraoperative Entrustment Skills

Toolkits to assess progressive resident autonomy are integral to the movement toward competency-based surgical education. OpTrust is one such tool validated for intraoperative assessment of both faculty and resident entrustment behaviors. We developed a supplementary tool to OpTrust that would aid faculty and residents in making meaningful improvements in entrustment behavior by providing talking points and reflection items tailored to different motivational styles as defined by Regulatory Focus Theory (RFT). Existing literature about surgical entrustment was used to build a list of sample dialogue and self-reflection items to use in the operating room. This list was distributed as a survey to individuals familiar with OpTrust and RFT, asking them to categorize each item as Promotion-oriented, Prevention-oriented, or Either. The respondents then met to discuss survey items that did not reach a consensus until the group agreed on their categorization. University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin Michigan Medicine, Ann Arbor, Michigan PARTICIPANTS: Clinician and education researchers familiar with intraoperative entrustment and RFT RESULTS: Eight respondents completed the survey categorizing the talking points and reflection items by RFT (100% response rate). Six of these respondents attended the additional meeting to discuss discordant items. The input from this panel was used to develop "TrustEd," the supplementary tool that faculty and residents can quickly reference before beginning a case. Although tools such as OpTrust allow intraoperative entrustment behaviors to be quantified, TrustEd offers concrete strategies for faculty and residents who are interested in improving those behaviors over time. Further study is needed to assess whether the use of TrustEd does in fact lead to durable behavior change and improvement in OpTrust scores.

SMaRT Assessment Tool: An Innovative Approach for Objective Assessment of Flap Designs.

The teaching and assessment of ideal surgical markings for local flaps required for optimal aesthetic and functional outcomes remain a challenge in the present era of competency-based surgical education. The authors utilized the bilobed flap for nasal reconstruction as a proof of concept for the development of an innovative objective assessment tool based on statistical shape analysis, with a focus on providing automated, evidence-based, objective, specific, and practical feedback to the learner. The proposed tool is based on Procrustes statistical shape analysis, previously used for the assessment of facial asymmetry in plastic surgery. For performance boundary testing, a series of optimal and suboptimal designs generated in deliberate violation of the established ideals of optimal bilobed flap design were evaluated, and a four-component feedback score of Scale, Mismatch, Rotation, and Translation (SMaRT) was generated. The SMaRT assessment tool demonstrated the capacity to proportionally score a spectrum of designs (n = 36) ranging from subtle to significant variations of optimal, with excellent computational and clinically reasonable performance boundaries. In terms of shape mismatch, changes in SMaRT score also correlated with intended violations in designs away from the ideal flap design. This innovative educational approach could aid in incorporating objective feedback in simulation-based platforms in order to facilitate deliberate practice in flap design, with the potential for adoption in other fields of plastic surgery to automate assessment processes.

Defining the need for faculty development in assessment

BackgroundHigh-quality workplace-based assessments are essential for competency-based surgical education. We explored education leaders’ perceptions regarding faculty competence in assessment. MethodsSurgical education leaders were surveyed regarding which areas faculty needed improvement, and knowledge of assessment tools. Respondents were queried on specific skills regarding (a)importance in resident/medical student education (b)competence of faculty in assessment and feedback. ResultsSurveys (n = 636) were emailed, 103 responded most faculty needed improvement in: verbal (86%) and written (83%) feedback, assessing operative skill (49%) and preparation for procedures (50%). Cholecystectomy, trauma laparotomy, inguinal herniorrhaphy were “very-extremely important” in resident education (99%), but 21–24% thought faculty “moderately to not-at-all” competent in assessment. This gap was larger for non-technical skills.Regarding assessment tools, 56% used OSATS, 49% Zwisch; most were unfamiliar with all non-technical tools. SummaryThese data demonstrate a significant perceived gap in competence of faculty in assessment and feedback, and unfamiliarity with assessment tools. This can inform faculty development to support competency-based surgical education.

Developing Comprehensive Operative Capture Evaluation Tools for Endovascular Aortic Repair: The ENDORATE-EVAR Framework

As we move toward competency-based surgical education, detailed and actionable feedback to trainees is critical to ensure adequate and efficient skill development. Comprehensive operative capture systems such as the Operating Room Black Box (Surgical Safety Technologies, Inc, Toronto, Ontario, Canada), which continuously record and synchronize multiple sources of intraoperative data, have recently been developed for hybrid angiosuites to provide targeted feedback to surgical teams. The objective of this study is to develop step, error and event frameworks that can evaluate technical performance in endovascular aortic repair (EVAR) procedures comprehensively captured by the Operating Room Black Box system.

Australian orthopaedic surgery training: Australian Orthopaedic Association's strategic education review.

The Australian Orthopaedic Association (AOA) is the peak professional body for orthopaedic surgeons in Australia and is responsible for their training and continuing medical education. The 2012 AOA strategic education review employed a gap analysis to identify issues and generate a roadmap for the enhancement of AOA's education and training activities. This paper describes the process and outcomes of this review, which led to the 'AOA 21' Education Re-design Project, and the review's relevance to surgical education in Australia. The AOA strategic education review was undertaken by international clinician education and orthopaedic experts, and involved AOA staff, fellows and trainee members throughout Australia. This review progressed through four phases: a review of current training; a global 'best-practice' perspective; a set of aspirational goals; and a roadmap for implementation. Seven key strengths (e.g. camaraderie in training and surgical skills teaching) and 15 challenges (e.g. 'non-technical' skills teaching, subjective methods of decision making and inadequate assessment practices) were identified in the review stage. Sixteen major recommendations for improvements incorporating current or emerging world's best education practices were targeted in an 8-year implementation framework. The AOA's strategic education review serves as a roadmap for other specialty training organizations to review their programmes and implement contemporary best practices in surgical training. The AOA 21 project has positioned orthopaedic surgery as a leader in competency-based surgical education and training in Australia.

A Binational Need Assessment to Define the Level of Endovascular Expertise Required by Vascular Surgical Trainees

There has been a shift toward competency-based surgical education programs to improve trainee performance and achieve better patient outcomes. Endovascular procedures comprise a significant volume of vascular surgery, but the current methods for assessing the endovascular competence of vascular trainees in Australia and New Zealand are suboptimal. The objective of this study was to perform a need assessment to define the scope of endovascular expertise required by vascular surgical trainees to later aid in the development of novel surgical training assessment tools. A modified Delphi method was used to achieve expert consensus. Fifty-three key stakeholders in vascular surgical education and training (SET) in Australia and New Zealand were invited to take part in the 2-stage survey. Experts were asked which procedures they considered to be requisite for vascular surgery trainees and at which SET level competence should be achieved. The results were reiterated to the expert panel in the second stage, and consensus considered achieved if over 75% of experts were in agreement. In the first stage 25 experts reached consensus that competence in 18 of the 26 procedures should be requisite for SET trainees. Twenty-two experts responded to the second stage and consensus was achieved for 12 out of 14 of the procedural items with mean percentage of experts in agreement being 90%. A need assessment using a modified Delphi method has achieved consensus among experts in vascular surgery regarding the endovascular procedures considered to be requisite for vascular surgery trainees in Australia and New Zealand.

How Do Thresholds of Principle and Preference Influence Surgeon Assessments of Learner Performance?

The present study asks whether intraoperative principles are shared among faculty in a single residency program and explores how surgeons' individual thresholds between principles and preferences might influence assessment. Surgical education continues to face significant challenges in the implementation of intraoperative assessment. Competency-based medical education assumes the possibility of a shared standard of competence, but intersurgeon variation is prevalent and, at times, valued in surgical education. Such procedural variation may pose problems for assessment. An entire surgical division (n = 11) was recruited to participate in video-guided interviews. Each surgeon assessed intraoperative performance in 8 video clips from a single laparoscopic radical left nephrectomy performed by a senior learner (>PGY5). Interviews were audio recorded, transcribed, and analyzed using the constant comparative method of grounded theory. Surgeons' responses revealed 5 shared generic principles: choosing the right plane, knowing what comes next, recognizing normal and abnormal, making safe progress, and handling tools and tissues appropriately. The surgeons, however, disagreed both on whether a particular performance upheld a principle and on how the performance could improve. This variation subsequently shaped their reported assessment of the learner's performance. The findings of the present study provide the first empirical evidence to suggest that surgeons' attitudes toward their own procedural variations may be an important influence on the subjectivity of intraoperative assessment in surgical education. Assessment based on intraoperative entrustment may harness such subjectivity for the purpose of implementing competency-based surgical education.

Optimizing resident operative self-confidence through competency-based surgical education modules: are we there yet?

Self-confidence is the belief in one's ability to perform and can be enhanced by training. Surgical education should aim to optimize trainee confidence. We designed three procedure-specific competency-based modules to teach vaginal hysterectomy (VH), anterior (AR) and posterior repair (PR) to novice gynecology residents. We hypothesized each module would improve self-confidence and satisfaction during index procedure performance in the operating room. This was an ancillary analysis of a larger randomized-controlled trial of gynecologic educational interventions. Residents at three Canadian universities were included if they had previously performed fewer than five index procedures independently. Intervention residents received educational modules; controls engaged in self-directed learning. All residents performed one or more of the three surgeries and filled out a validated Self-Confidence Scale and a Satisfaction Scale. Scores were compared between groups. Correlations were sought between self-confidence and various variables. Forty-six residents at three Canadian universities were randomized (21 intervention, 25 control). Most residents had never performed the index procedure. Overall, self-confidence was significantly higher (p = 0.021) in the intervention group for VH, but not for AR and PR (p = 0.94 and p = 0.12, respectively). Compared with controls, self-confidence was also significantly higher in intervention residents who had never performed VH (p = 0.026) or PR (p = 0.027) and in first and second year intervention residents. There was a positive correlation between self-confidence and satisfaction. Surgical modules improved self-confidence preferentially in the most junior residents and for more complicated procedures. The wide self-confidence ranges observed suggest that optimization should be an important goal for surgical educators.

Progressive Surgical Autonomy Observed in a Hand Surgery Resident Clinic Model

Resident clinics (RCs) are intended to catalyze the achievement of educational milestones through progressively autonomous patient care. However, few studies quantify their effect on competency-based surgical education, and no previous publications focus on hand surgery RCs (HRCs). We demonstrate the achievement of progressive surgical autonomy in an HRC model. A retrospective review of all patients seen in a weekly half-day HRC from October 2010 to October 2015 was conducted. Investigators compiled data on patient demographics, provider encounters, operational statistics, operative details, and dictated surgical autonomy on an ascending 5 point scoring system. A tertiary hand surgery referral center. A total of 2295 HRC patients were evaluated during the study period in 5173 clinic visits. There was an average of 22.6 patients per clinic, including 9.0 new patients with 6.5 emergency room referrals. Totally, 825 operations were performed by 39 residents. Trainee autonomy averaged 2.1/5 (standard deviation [SD] = 1.2), 3.4/5 (SD = 1.3), 2.1/5 (SD = 1.3), 3.4/5 (SD = 1.2), 3.2/5 (SD = 1.5), 3.5/5 (SD = 1.5), 4.0/5 (SD = 1.2), 4.1/5 (SD = 1.2), in postgraduate years 1 to 8, respectively. Linear mixed model analysis demonstrated training level significantly effected operative autonomy (p = 0.0001). Continuity of care was maintained in 79.3% of cases, and patients were followed an average of 3.9 clinic encounters over 12.4 weeks. Our HRC appears to enable surgical trainees to practice supervised autonomous surgical care and provide a forum in which to observe progressive operative competency achievement during hand surgery training. Future studies comparing HRC models to non-RC models will be required to further define quality-of-care delivery within RCs.

Comparison of Canadian and Swiss Surgical Training Curricula: Moving on Toward Competency-Based Surgical Education

Quality of surgical training in the era of resident duty-hour restrictions (RDHR) is part of an ongoing debate. Most training elements are provided during surgical service. As exposure to surgical procedures is important but time-consuming, RDHR may affect quality of surgical training. Providing structured training elements may help to compensate for this shortcoming. This binational anonymous questionnaire-based study evaluates frequency, time, and structure of surgical training programs at 2 typical academic teaching hospitals with different RDHR. Departments of Surgery of University of Basel (Basel, Switzerland) and the Queen's University (Kingston, Ontario, Canada). Surgical consultants and residents of the Queen's University Hospital (Kingston, Ontario, Canada) and the University Hospital Basel (Basel, Switzerland) were eligible for this study. Questionnaire response rate was 37% (105/284). Queen's residents work 80 hours per week, receiving 7 hours of formal training (8.8% of workweek). Basel residents work 60 hours per week, including 1 hour of formal training (1.7% of working time). Queen's faculty and residents rated their program as "structured" or "rather structured" in contrast to Basel faculty and residents who rated their programs as "neutral" in structure or "unstructured." Respondents identified specific structured training elements more frequently at Queen's than in Basel. Two-thirds of residents responded that they seek out additional surgical experiences through voluntary extra work. Basel participants articulated a stronger need for improvement of current surgical training. Although Basel residents and consultants in both institutions fear negative influence of RDHR on the training program, this was not the case in Queen's residents. Providing more structured surgical training elements may be advantageous in providing optimal-quality surgical education in an era of work-hour restrictions.

Effect of Process Changes in Surgical Training on Quantitative Outcomes From Surgery Residency Programs

The purpose of this article is to review the literature on process changes in surgical training programs and to evaluate their effect on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification. A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: surgery residency training, surgical education, competency-based surgical education, ACGME core competencies, ABSITE scores, and ABS pass rate. Our initial search list included 990 articles on surgery residency training models, 539 on competency-based surgical education, 78 on ABSITE scores, and 33 on ABS pass rate. Overall, 31 articles met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 5/31, 19/31, and 6/31 articles on process changes in surgical training programs had a positive effect on patient care, medical knowledge, and ABSITE scores, respectively. ABS certification was not analyzed. The other ACGME core competencies were addressed in only 6 studies. Several publications on process changes in surgical training programs have shown a positive effect on patient care, medical knowledge, and ABSITE scores. However, the effect on ABS certification, and other quantitative outcomes from residency programs, have not been addressed. Studies on education strategies showing evidence that residency program objectives are being achieved are still needed. This article addresses the 6 ACGME Core Competencies.

Teaching Vaginal Surgery to Junior Residents: Initial Validation of 3 Novel Procedure-Specific Low-Fidelity Models

Competency-based surgical education relies on operative models to teach surgical skills within a curriculum. Low fidelity simulation has been shown to improve surgical performance. Our objectives were: to develop procedure-specific models to teach anterior repair (AR), posterior repair (PR), and vaginal hysterectomy (VH) to junior residents; to establish model reliability and validity. Residents were randomized to control (no training) and intervention (model training) groups. They were filmed while performing a series of tasks. Experts were also filmed. Each video was scored by 2 blinded raters. Multicenter collaboration within the Western Society of Pelvic Medicine (Vancouver, Calgary, and Edmonton). Face and content validity were evaluated. A standard scoring tool was developed for performance evaluation. Interrater reliability was assessed using intraclass correlation coefficient. Cronbach α was calculated for internal consistency. Jonckheere-Terpstra test verified whether the scores increased with operator skill level. A total of 14 junior gynecology residents, 2 urogynecology fellows, and 3 staff urogynecologists were rated by a total of 6 gynecologic surgeons who scored 42 videos each. Experienced pelvic surgeons from 3 participating sites agreed the models captured essential elements of real surgical skills (face validity) and of the true procedures (content validity). Intraclass correlation coefficient was adequate (AR = 0.86, PR = 0.90, and VH = 0.87). Cronbach α for the total scores was adequate (AR = 0.85, PR = 0.8, and VH = 0.71). Performance score increased with operator skill level for all 3 procedures (AR, p = <0.001; PR, p = 0.008; and VH, p = 0.007). Our low fidelity procedure-specific vaginal surgery models had adequate initial validity. Future research will investigate transferability of acquired skills to the operating room.

Considering Educational Work-Hour Guidelines in the Global Orthopaedic Community

I hear and I forget. I see and I remember. I do and I understand. —Confucius (551-479 b.c.) The presidents of the Australian, British, Canadian, New Zealand, and South African Orthopaedic Associations join those of the American Orthopaedic Association and the American Academy of Orthopaedic Surgeons to form the Carousel Presidents organization. More than simply sharing English as their principal language of medical communication, the respective associations share common challenges and learn relevant solutions that are applicable to orthopaedic practice and education around the globe. One such endeavor that shares commonality across the continents is trainee education and the evolving regulatory pressures that orthopaedic educators face in the regulation of trainee duty hours in the new millennium. As Confucius suggested, to do is to understand … and to learn. In the tradition of William Halsted, we in the surgical disciplines particularly respect this tenet of education as it relates to the mastery of technical skills. However, it is this same need to acquire technical proficiency that produces additional consternation over the notion of work-hour limits in a world of time-defined surgical education. Three underlying principles that are germane to resident duty-hour guidelines, as well as the reaction to such efforts, are universally applicable to all orthopaedic communities despite variation in the actual rules in each country. The central issue driving reform around the world is the need to improve patient safety and reduce medical errors related to fatigue of the treating physician. Two additional issues that have arisen in reaction to the duty-hour dilemma are the realization of the need for a transition to competency-based surgical education from the present time-defined training periods and a heightened awareness of the erosion of medical professionalism that is seemingly implicit in an environment that legislates a clock-punching mentality. Indeed, one might reasonably …

A structured conference program improves competency-based surgical education

A structured conference program improves competency-based surgical education

Educational challenges in vascular surgery: An Australasian response

In Australia and New Zealand, training requirements in vascular surgery have substantially changed since 2002. Training in general surgery is no longer required. Trainees in vascular surgery need to be competent in open vascular surgery and in performing and interpreting vascular ultrasound imaging. They must also master a full range of endovascular procedures, including cannulation of arteries, and angioplasty and stenting procedures, and endoluminal repair of aneurysms with stent grafting. Applicants complete a rigorous selection process and are ranked nationally. Training is started in postgraduate year 3 or at any time beyond that. The 5-year program is the competency-based surgical education training (SET) program. The trainees sit an examination at the end of the SET 1 and also an exit examination in SET 5. Before the final examination, the trainees must have performed 400 major cases as primary operators and 150 peripheral percutaneous interventions. In addition they must satisfy the requirements of the on-line in-service examinations and show adequate ultrasound case volumes and completion of research projects.

A structured conference program improves competency-based surgical education

Background Work hour restrictions and new educational standards pose substantial challenges for modern residency programs. We present results from an institutional effort to improve resident education using a competency-based conference program. Methods The conference program is a weekly 3-hour mandatory block of protected time including a formal lecture series and a modular series tailored to resident level. A comprehensive survey was administered to all general surgery residents before (2005) and after (2006) implementation of the new conference program and included specific items related to the 6 competencies. Results Scores for 16 competency-related items all showed statistically significant improvement. We also found improvements in residents' perceptions of the faculty. Overall, the new conference program was rated positively by 98% of residents. Conclusions Implementation of a structured conference program resulted in significant improvement in residents' evaluation of their education in the 6 competencies and improved their perceptions of the faculty.