Transition from Time-Based Education to Competency-Based Education in Surgical Training: A Descriptive Case Study

Abstract

The traditional Time-Based Education (TBE) model in higher education and Graduate Medical Education (GME) has been increasingly criticized for prioritizing “seat-time” over demonstrated mastery, often resulting in gaps between educational outcomes and workforce expectations. Competency-Based Education (CBE) has emerged as an outcome-oriented approach to address these limitations by emphasizing the demonstration of knowledge, skills, and abilities required for professional practice. However, the processes by which training programs transition from TBE to CBE remain insufficiently understood, particularly in high-stakes environments such as surgical training.

This dissertation examines the processes, results, and experiences of the transition from TBE to CBE within a U.S. surgical residency program. Using a descriptive case study design, data were collected through document analysis and semi-structured interviews with ten stakeholders involved in the CBE working group, including program leadership, faculty, residents, and staff.

Findings reveal that the transition was guided by a multi-framework approach integrating the SCORE content framework, the 12-step test development process, Miller’s pyramid of assessment, and Kern’s six-step curriculum design model. Importantly, the study demonstrates that the 12-step test development process was extended beyond individual test development to support the design of a program of assessment integrating multiple evaluation methods. As a result, key artifacts were developed, including a competency framework, task inventory, foundational resident oral examination (FOE), performance standards for EPAs and FOE, a program of assessment, and the overall standard for the matriculation of foundational surgical residents. Thematic analysis of stakeholder interviews identified four major themes: systemic and cultural barriers, professional expertise and support, infrastructure and requirements, and strategic recommendations for CBE implementation.

These findings highlight the transition as a complex organizational change process requiring alignment among curriculum, assessment, and institutional systems. This study contributes to the literature by providing a program-level blueprint for transitioning to competency-based education and by extending traditional test development frameworks to support programmatic assessment systems. The findings offer practical insights for surgical residency programs and other professional training contexts seeking to implement competency-based education while ensuring learner competence and patient safety.