A competency framework in cardiothoracic surgery for training and
revalidation — an international comparison
Tim T. Wanga, Kamran Ahmeda,*, Vanash M. Patela, Leanne Harlinga, Muhammed Jawada,
Ara Darzia, Ludwig Karl von Segesserb, Thanos Athanasioua
aDepartment of Surgery and Cancer, Imperial College London, London, UK
bDepartment of Cardiovascular Surgery, University Hospital Vaudois, CHUV, Lausanne, Switzerland
Received 24 October 2010; received in revised form 27 December 2010; accepted 4 January 2011; Available online 26 February 2011
The conventional methods of education, certification and recertification in cardiothoracic surgery face a paradigm shift in line with recent
innovations in diagnostics and therapeutics. The attributes of a competent clinician entail proficiency in knowledge, communication, teamwork,
management, health advocacy, professionalism and technical skills. This article investigates the skills requiredfor a cardiothoracic surgeon to be
competent. The relevant practice of certification and recertification across various regions has also been explored. Validated and competency-
based curricula should be designed to develop core competencies to successfully integratethem into practice. Challenges to the implementation
of such curricula and potential solutions are explored. Patient safety remains the ultimate aim to ensure excellence of both competency and
# 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Keywords: Skill; Training; Assessment; Education; Cardiothoracic; Competence
Technological advancements of catheter-based techni-
ques in cardiology, interventional radiology and vascular
surgery have altered and challenged the need for estab-
lished cardiothoracic procedures . Diagnostic and ther-
apeutic innovations in cardiothoracic surgery have also
influenced the prerequisites to overcome the effects of
learning curves . Current changes in referral practice
request ever more complex procedures frequently involving
an elderly population with increased co-morbidities. A
heightened sense of patient safety, public accountability
and reduced working hours, further challenges training in
this specialty [3—5]. Nevertheless, cardiothoracic surgery
remains exposed to the high risk of adverse events,
significantly challenging the competence and performance
of the surgeon. Yet, training and evaluating competence
remain the least systematic or standardised elements of
‘mission critical’ mandate to develop education for trainees
and specialists alike [1,7].
This article aims to investigate the components of
competency required of a cardiothoracic practitioner. The
development and assessment of technical and non-technical
skills have been illustrated. Barriers to the implementation
of competency-based curricula are explored, and potential
solutions are discussed. Finally, the practice of certification
and recertification across various regions is also described as
it is strongly related to maintenance of competent cardi-
2. Components of competence
Proficient practice requires competence in technical and
non-technical skills. The Royal College of Physicians and
Surgeons of Canada (RCPSC) has outlined key competencies
of a clinician in the CanMEDS (Canadian Medical Education
Directives for Specialists) competency framework; a medical
expert, a communicator, a collaborator, a manager, a health
advocate, a scholar and a professional . This framework
represents an amalgamation of societal need, empirical
research, fellows’ expertise and the College consensus since
the early 1990s . CanMEDS was first approved by the
RCPSC’s governing council in 1996 but has now been adopted
worldwide. Recently, other training bodies such as General
Medical Council (GMC) in the UK and the American Boards of
European Journal of Cardio-thoracic Surgery 40 (2011) 816—825
* Corresponding author. Address: Department of Surgery and Cancer, 10th
Floor, QEQM-Wing, St Mary’s Campus, London, W2 1NY, UK.
Tel.: +44 20 3312 7639; fax: +44 20 3312 6309.
E-mail address: email@example.com (K. Ahmed).
1010-7940/$ — see front matter # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Medical Specialties (ABMS) have also defined their individual
frameworks.1,2However, the basic components of all these
guidelines remain the same.
As per the traditional Halstedian ‘see one, do one, teach
one’ methodology; tutors defined expectations of technical
skill and assessed the trainees’ dexterity and procedure-
specific psychomotor skills . Currently, competence is not
merely the possession of knowledge, skills and the ability to
perform the activities of a surgeon in line with expected
standards.3Technical proficiency must be coupled with an
ability to organise, innovate and co-operate with colleagues,
allied health professionals and managers to fully integrate
into the wider organisational environment. Competence
entails a predefined set of basic criteria, which practicing
surgeons have to fulfil. Superior performance depends on a
surgeon’s ability to excel in a dynamic setting with varying
challenges. This requires additional skills and clinical
experience beyond the mandate of basic competence.
3. Competency of non-technical skills
Non-technical skills entail the critical cognitive and
interpersonal abilities that complement surgeons’ technical
abilities . Most adverse events in surgery have been
reportedtooccur asaresult offailure innon-technical rather
than technical performance. Communication failure is a
causal factor in 43% of errors made in surgery . Twenty-
seven percent of the health-care claims have been found to
be due to diagnostic and cognitive errors in the operating
theatre . For the purpose of cognitive and team training,
high-risk industries such as civil aviation, nuclear power and
oil exploration have traditionally employed crew resource
management (CRM) to train their employees in communica-
tion, teamwork, leadership, judgment, decision-making and
situational awareness . Surgical education never expli-
citly addressed these factors until recently [10,13,14]. This
section highlights the components of non-technical skills as
well as methods of training and assessing each component in
line with CanMEDS framework (Figs. 1 and 2). These
components are important for residents and also for
practicing specialists, and can be classified as follows.
3.1. Medical expert
This component entails maintaining up-to-date knowl-
edge of the current clinical, surgical, biomedical and
epidemiological concepts and application of this knowledge
to provide optimal patient-centred care . These attributes
lead to evidence-based clinical decisions and therapeutic
interventions . The recognition of the limits of their own
expertise and timely consultation with other health profes-
sionals is essential.
3.1.1. Developing medical expertise
The traditional repertoire consisting of clinical teaching,
lectures, seminars, workshops, journal clubs and self-
directed learning have been expanded by innovative
computer-assisted instruction and standardised simulation
models. For the specialists, lifelong development of knowl-
edge and skills is facilitated by continuing medical education
(CME) . CME is an integral component of continuing
professional development (CPD) that encompasses other
domains required for competent practice, such as education,
training, audit, management, team building and commu-
nication . Through this process, cardiothoracic surgeons
manage their ownprofessional development, meet the needs
T.T. Wang et al./European Journal of Cardio-thoracic Surgery 40 (2011) 816—825
Fig. 1. Components of competence described by various educational organi-
sations (ABMS: ABMS Maintenance of Certification, http://www.abms.org/
Maintenance_of_Certification/ABMS_MOC.aspx, 2009; GMC: Good Medical
Practice Appraisal Framework 28/10/2009, http://www.gmc-uk.org/Frame-
work_4_3.pdf_snapshot.pdf. General Medical Council, 2009).
Fig. 2. Training and assessment tools.
1ABMS. ABMS Maintenance of Certification. http://www.abms.org/Mainte-
2GMC. Good Medical Practice Appraisal Framework 28/10/2009 http://
www.gmc-uk.org/Framework_4_3.pdf_snapshot.pdf. General Medical Council
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