Cross-specialty training in the era of competency-based education.

An article discussing a proposed curriculum to provide surgical training to family physicians is included in this issue of the journal.1 We decided to publish it with accompanying commentaries for and against the proposal in order to facilitate an informed debate. The argument for enhancing the surgical skills of family physicians is that they could provide surgical care for patients in remote locations, where surgeons may not be based.2 Those against the proposal question its premise; patients in remote areas have remarkably good access to surgical care and they expect the same standard of care as patients elsewhere.3 The proposal comes at a time when specialty training is undergoing change. Rather than designing a training program as a time-based process for the sequential acquisition of knowledge and skill, it is suggested that progression of surgical training should depend on the acquisition of defined competencies. The Royal College of Physicians and Surgeons of Canada has given this transformation the name "competence by design" (CBD). While CBD implementation currently deals with postgraduate medical education (residency), the intention is to include the postcertification career training currently referred to as "continuing professional development" (CPD). One promised aspect of CBD is that it will permit surgeons to tailor their education to fit the practice required in their particular situations. Some surgeons will restrict their practices to areas of special interest (e.g., arthroplasty, hepatobiliary surgery); others will undertake cross-specialty training to expand their competencies (e.g., cesarian section performed by general surgeons). Where then does this proposal to train family physicians to undertake major surgery fit in the era of CBD? Competence by design removes the element of time but does not alter the other fundamentals of training. All course modules have 4 elements: prerequisites, a learning phase, testing and maintenance of competence. Currently, the prerequisites for a trainee to undertake advanced surgical training is successful completion of the Principles of Surgery (POS) course and examination. While some credit should be given to certified family physicians, the proposal would need to include additional training and testing in the fundamentals of surgery to meet the validated prerequisite standard. Competence by design will accommodate a practising surgeon learning a new procedure where established surgical skills facilitate the acquisition of new skills. On the other hand, there is no reason to believe that nonsurgeons, even if they have completed POS, would become competent more quickly than residents in training. If this is true, the curriculum for enhanced surgical skills cannot be completed within a year. More likely it would take the same effort and time as a conventional surgical training program — without the determined checks and balances of a certified training program. Patients and regulatory authorities expect physicians with surgical privileges to have passed standard tests of competence. Testing of cross-specialty competencies should remain within the responsibility of the subspecialty. Testing the wide range of competencies proposed in this curriculum will be logistically difficult. Training and testing within the time frame proposed is impossible. Finally, maintenance of competence has 3 elements: practice of the specific skill, practice of related skills and CPD. The premise of the proposal is that insufficient volumes of work are available in remote areas to maintain conventionally trained surgeons. In this situation, the family physician will be unable to maintain competence by practice of the specific or related skills and will have to spend an inordinate amount of time undertaking coursebased CPD. Provision of surgical services in a country as large as Canada requires collaboration between several levels of government, hospital authorities and several medical specialties. While the lack of a surgeon is often cited as the reason why a patient has to be transferred, the true logistical evaluation is always more complex. Surgeons who undertake care have to be prepared to deal with unexpected, difficult intraoperative findings and complex postoperative courses. Adages such as "preparing for the worst is better than hoping for the best" and "the last thing a surgeon learns is when not to operate" have stood the test of time. Good care of residents of remote areas must include close collaboration and