Two Steps Forward, One Back

by Harry S. Nayar, MD, MBE and Steve J. Kempton, MD

Plastic surgery education is undergoing an important transformation by changing its emphasis from volume to competency-based training, embodied as the Plastic Surgery Milestones Project.  Formally, the intention of this program is for use in the longitudinal evaluation of residents as they progress through training.  Resident evaluation is centered on core subjects in plastic surgery where they are graded on a level 1 through level 5 scale.  Each level contains a textual description on what the resident should demonstrate in order to fit within that category.  For example, in order to attain a level 5 rating for patient care matters in the subject of Maxillofacial Trauma, a resident must be deemed to appropriately “manage complex secondary deformities (e.g. enophthalmos or malocclusion).”  This new evaluation philosophy represents the most ambitious shift in plastic surgery education since the advent of integration more than a decade ago.

On our view, and somewhat of a philosophical one, the milestones project is driven by the notion that one’s surgical skill cannot be captured by numbers alone.  That is to say, competency is not necessarily predicated on or, at the very least, linearly correlated with surgical volume.  Thus changing the paradigm from volume-based training to competency-based training, especially in an era of duty hour reform, is undeniably appealing, though somewhat problematic in practice.  We all know that repairing 6 cleft palates does not reliably produce a competent cleft palate surgeon; some might take to the craft after their first, others require more.  However, for all of us it is comforting to know, even if only for the sake of credentialing, that in the eyes of the ACGME we have done enough.  On the other hand, who is to say that one person’s interpretation of level 5 competence would be the same as another individual in a different part of the country, with a different set of values?  Faculty at each of our institutions have all been trained as expert surgeons, not necessarily as expert educators, and, therefore, may themselves need training on how to objectively assess residents and promote advancement to higher levels.

We have previously written on how simulation promises to change the landscape of surgical education.  As an evaluation platform, its ability to marry and simultaneously test cognitive and procedural elements reveals an attractive potential for objectivity that has been shown to translate to the operating room.  Cognitive task analysis appears to be the most promising method to date toward the development of a comprehensive, competency-based simulation experience.  The success of these simulators, however, still remains dependent on faculty to be present for immediate and post simulation feedback, as well as to extend those lessons into the operating room.

Any initiative as sweeping as the milestones project is bound to bring with it certain challenges, as evidenced by a recent survey that revealed only 22% of programs feel ready to fully implement this effort (1). On the surface, we seem to be trading the objectivity, simplicity, and standardization of volume-based training for the comprehensiveness and superior educational merits of competency-based metrics.  We submit that a crucial step towards facilitating this transition lies in evaluating and redesigning the approach to resident assessment, including formalizing faculty educational training and exploring the role of simulation.


Sillah, N. M., Ibrahim, A. M., Lau, F. H., et al. The New ACGME Next Accreditation System (NAS) Milestones Evaluation System: What is Expected and How are Plastic Surgery Residency Programs Preparing? Plastic and reconstructive surgery, 2015.

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