34th Annual Scientific Meeting proceedings

When the first surgery residencies were developed in the early 1900’s, the development of expertise was based on the phrase ‘see one, do one, teach one’ (Halstead, 1904). In the interim, the specialism of surgery has evolved tremendously, and residency programs have become widespread. The goal of modern residencies is qualification of specialist surgeons who have expert levels of knowledge, skills and competence. To achieve these goals, human surgery residency training has increased in complexity and so have educational techniques utilized to assist in the development of expertise. During this session we will explore the rationale for the widespread inclusion of competency-based education (CBE) in human surgery residencies and applications in veterinary residency training. 

Initial moves away from ‘see one, do one, teach one’ were based on concerns about patient safety, with the need for additional instruction and skills training prior to operating on patients widely recognized (Rohrich, 2006). With this recognition, educational strategies were developed to assist residents with acquisition of skills at each stage and help them transition between steps. In the late 1970s, Dreyfus & Dreyfus were commissioned by the US Airforce to investigate how pilots could improve their skills without compromising safety. They developed a five-stage model of mental activities involved in directed skill acquisition (Dreyfus and Dreyfus, 1980). The five stages ‘novice, competence, proficiency, expertise and mastery’ were quickly adopted in human medical residency training. The Dreyfus model of development (Edgar, et al., 2023) is widely utilized as the framework for competency based medical education (CBME) and the development of milestones in human medical residency training (Accreditation Council for Graduate Medical Education, 2025).

Current assessment of skills development in veterinary residents is based on case logs. Whilst they are useful for ensuring adequate case exposure, the jump from assistant to primary surgeon can be large, and it may not always be clear to the learner how to move from one level to another. The zone of proximal development (Vygotsky, 1978) describes how learners might navigate the gap between existing skill level and aspirational level. This concept, originally used in childhood development, describes scaffolding for learners to progress from one level to another, which is like the five-stage model (Dreyfus and Dreyfus, 1980). If the skill level is too easy, learners will not develop their skills; if it is too difficult, learners may enter the ‘panic’ zone which also can inhibit learning. 

Core components of CBE include clearly defined competencies, which allow residents to know what they are expected to know and do and progressive milestones which allow them to benchmark their progress as they work toward specific competencies. Skills development is based on direct observation and feedback, with residents developing an awareness of their own learning needs through development of personal learning plans, informed by comparisons to milestones and feedback. Human surgery residencies have also moved away from traditional testing to assessment in the clinical environment due to evidence that this may be more accurate than traditional testing methods (Purdy et al., 2022).

In contrast with traditional educational methods, CBE is driven by learners with an emphasis on seeking formative feedback to drive self-assessment and growth. In human medicine training, residents commonly use milestones as guidelines for training expectations, to self-assess their performance and seek feedback, reflect on areas for improvement and drive their learning. Residents using CBE to generate their own goals have greater flexibility of learning; they can tailor their focus to concentrate on areas for improvement. A recent review demonstrates a need for research-based learning curves for specific veterinary surgical procedures (Simons et al., 2024); such learning curves or milestones provide a framework allowing residents to drive their own learning.  

Once learners have identified an area for surgical skill development, they may refine their skills using deliberate practice. In veterinary residencies this mostly includes the use of models or cadavers.  Whilst these are widely available, opportunities for formative assessment and feedback from supervisors to complement deliberate practice can be limited for residents (Simons et al., 2024).  Perry et al., (2020) found frequent mismatches between resident and supervisor perceptions regarding positive feedback delivery and importance of dialogue. A ‘no news is good news’ culture prevailed in many institutions with residents only receiving feedback after a mistake, rather than as part of a formative learning process (Perry et al., 2020).  The introduction of milestones could help to facilitate feedback conversations by allowing residents to ask for feedback on specific aspects of training and track development.

Potential challenges to implementation of the CBE framework in practice include the requirement to develop CBE frameworks for veterinary residents, requirements for clinicians to be trained in assessment and feedback, time required for supervisors to supervise and provide feedback, a shift away from the ‘no news is good news’ feedback culture (Perry et al., 2020) and development of tools to track progress. Whilst these challenges should be acknowledged, exposing residents to greater opportunities for self-reflection and personal goal setting could ultimately allow the development of the essential components of lifelong learning to maintain expertise, long after residency training is completed.

References

1. Accreditation Council for Graduate Education (2025) Milestones Guidebook for Residents and Fellows available online: https://www.acgme.org/globalassets/PDFs/Milestones/MilestonesGuidebookforResidentsFellows.pdf
2. Dreyfus, S.E. & Dreyfus, H. (1980). A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition.  California University Berkeley Operations Research Center. Available from: http://www.dtic.mil/dtic/index.html [downloaded 12 May 2025]
3. Edgar, L., Guralnick, S., Heath, J.K. and McLean, S. (2023) “Milestones Data for Learner and Program Improvement,” presented at the Accreditation Council for Graduate Medical Education Annual Educational Conference, Nashville, TN.
4. Halstead, W.S. (1904) The Training of the surgeon. Bulletin of the John Hopkins Hospital, 15, 267-275.
5. Purdy, A. C., de Virgilio, C., & Amersi, F. (2022). Competence Is About Skill, Not Procedure Case Numbers-Reply. JAMA surgery, 157(1), 81–82
6. Rohrich, R.J. (2006) “See One, Do One, Teach One”: An Old Adage with a New Twist. Plastic and Reconstructive Surgery, 118, 257-258.
7. Simons, M. C., Hunt, J. A., & Anderson, S. L. (2024). Trained to cut? A literature review of veterinary surgical resident training. Veterinary surgery, 53(5), 791–799.
8. Vygotsky, L. (1978) Mind in society: the development of higher psychological processes, Cambridge, MA: Harvard University Press, pp. 86-91.