Introduction

The rising global cancer burden is a significant public health problem and is expected to rise by 47% between 2020 and 2040 [1]. Over 80% of all cancer patients need some form of surgical intervention, and less than 25% of these patients have access to effective surgical care in a timely manner [2]. A modeling study by Sung and colleagues suggested that demand for global cancer surgery will rise by 52%—between 2018 and 2040 [3]. This rising demand can be tackled by the availability of an adequate global healthcare workforce, in which surgical oncologists will play an important role [4]. The shortage of a trained workforce of surgical oncologists is one of the main barriers to providing the optimal surgical intervention needed for cancer patients [4]. Variations in global educational platforms, long training programs, and physician burnout are some of the contributing factors to the shortage of trained surgical oncologists [4, 5]. Therefore, the availability of a credible training framework and a sustainable certification pipeline for future surgical oncologists is critical to meet the global demand for an adequate healthcare workforce to provide surgical services to cancer patients.

The current educational programs in surgical oncology are based on a time-based construct that trains surgeons to function seamlessly in the multidisciplinary care of cancer patients [6]. Considerable global variations exist in surgical oncologists’ training paradigms and the certification timeline [7,8,9]. For example, in the USA, India, and Europe, a trainee spends between 9 and 17 years of training (premedical education to fellowship training) to become a certified surgical oncologist [7,8,9]. Of this time period, 3 to 7 years are spent in postgraduate/residency training and 1 to 3 years in fellowship training [8, 9].

Although this time-based system has worked well for decades, there are some pitfalls, such as a lack of flexibility in the training framework and timeline despite differences in students’ abilities and a lack of confidence in some of the graduating trainees for unsupervised practice [10,11,12]. Although assessment of competencies is included in this time-based format, most trainees will finish their training with a varying level of competency [12]. For these reasons, leaders in education have been proposing the model of competency-based medical education (CBME). CBME is an outcome-based approach for trainees to develop and demonstrate the necessary competence for clinical practice and is a significant shift from the current traditional format of timed-based training [12].

The aim of this article is to provide a review of the current time-based training system and CBME. The article will also compare and weigh the pros and cons of each system and its relevance to the training of surgical oncologists.

Competence in Medical Education

As defined by the Oxford English Dictionary, being “competent” is possessing the requisite qualifications for, or to be properly qualified [13]. Professional competence has been proposed as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotion, values, and reflections in daily practice for the benefit of the individual and community being served” [14]. In medical education, examination of the various conceptions behind the widely used terminology, such as “competence” or “competency,” can help to better understand the benefits and pitfalls of competency-based education. In 1978, the World Health Organization (WHO) defined the intended outcome of the competency-based program in medical education as “a health professional who can practice medicine at a defined level of proficiency, in accord with local conditions, to meet local needs” [15]. The competency framework in medical education is complex but has a demonstrable integration of numerous related objectives and the attainment of defined competencies that help to reach a set goal [11]. Therefore, the framework of competency-based medical education (CBME) can be best understood when contrasted with the framework of the current time-based medical education system.

Current Medical Education System

Rationale

The current medical education system was conceived based on the 1901 Flexner report, which highlighted the importance of adopting a biomedical model of medical education with scientific knowledge and its advancement as the defining principles of a modern physician [16]. The report triggered a fundamental reform in the standards and organization of the curriculum in medical education. The current time-based educational framework is based on the rationale that the integration of biomedical science in medical education enables the student to develop a strong medical foundation before moving to clinical practice [17, 18]. This led to the design of the current medical education curriculum in two phases, beginning with the pre-clinical phase, which focuses on basic science disciplines aimed at providing a strong scientific foundation for the clinical phase that follows. The clinical phase focuses on the clinical science relating to diagnosis, treatment, and patient management [18].

History

More than a century ago, medical education was plagued by lax admission standards, unscientific protocols, and unstandardized curricula [19, 20]. At the beginning of the twentieth century, several catalyzing events transformed medical education, of which principles articulated by Abraham Flexner, William Osler, and William Steward Halsted played an important role [17,18,19,20,21,22]. In 1910, Abraham Flexner’s landmark report, “Medical Education in the United States and Canada,” highlighted the lack of standardization, integration, inquiry, and failure to focus on professional identity formation in the education system practiced at that time [23]. The report recommended that medical schools be incorporated within the existing research universities, have a 4-year curriculum with basic science and clinical science content, have minimum admission requirements, and have physician-scientists actively engaged in teaching, research, and patient care [23]. This report served as a wake-up call to medical educators in North American and European countries to standardize their medical education processes [20, 23]. At around this time, William Osler championed the postgraduate training model, which focuses on bedside teaching, direct interaction with patients, and learning medicine from these experiences under the guidance of faculty clinicians [17, 20]. The result was the establishment of two critical components of undergraduate medical education, namely, the basic sciences and the clinical sciences [17]. Around the turn of the nineteenth century, William Halsted, credited as the father of surgical education, established the first formal general surgical residency program based on an apprenticeship model with hospital-based training [21]. The Halstedian model is considered one of the most durable models of postgraduate training for physicians in the history of medical education [22]. It consisted of a time-based structured training curriculum with structured educational content, actual experience with patients, escalating experience with patients, a period of supervised practice after training, and progressive assumption of responsibility until the acquisition of competence prior to entering practice [10, 22]. By the 1950s and 1960s, undergraduate and graduate medical education in North America, Europe, Australia, and Asia had evolved from a chaotic mix of institutions and practices to its modern framework with the participation of regulating bodies such as the American Medical Association (AMA) [19, 20], the United Kingdom (UK) General Medical Council (GMC) [24], the Medical Council of India (MCI) (replaced by the National Medical Commission (NMC) in 2019) [25, 26], and the formation of new regulating bodies in different regions of the world [20, 27,28,29].

Core Components of the Current Medical Education System

The current medical education system has been widely adopted throughout most of the twentieth century, and the majority of current physicians were trained under this system [30]. The current educational system is implemented in a university-based medical school and teaching hospital and comprises components such as (i) a time-based educational framework where all trainees complete the training program in a specified timeframe regardless of differences in trainees’ backgrounds and abilities; (ii) a knowledge acquisition-focused didactic curriculum with an emphasis on the efficient transfer of scientific and clinical information to the trainee; (iii) a hierarchical educational path where the teacher is responsible for the educational content, pace, and evaluation of the trainee; (iv) a summative assessment focused timeline of trainee’s competency with designated faculty inputs and required assessment tools; and (v) a certification process at the end of the training process for independent practice [10, 11].

Pros and Cons of the Current Medical Education System Based on the Implementation Process and Hurdles Encountered

The current medical education system is well established with the existing policies, regulations, and laws and does not pose a significant challenge in the implementation process [10]. In this time-based framework, all trainees complete the training program in a specified timeframe regardless of the competency status of individual trainees. The framework fits well with the needs of predictable clinical service scheduling [11].

Although the current system works well for both undergraduate and graduate medical education, it lacks a flexible training period, and postgraduate trainees are subjected to long work hours. In addition, it is felt by some that there can be an apparent lack of faculty supervision, sub-optimal assessment, and feedback. All of these can lead to a negative effect on the trainees’ overall well-being leading to increased medical errors and a lack of trainees’ confidence [11]. Moreover, healthcare professionals are unable to keep pace with the explosive growth in medical knowledge and technological advances. In addition, training physicians in managing emerging infectious and new environmental hazards can be difficult in the current fragmented, outdated, and static training platform [31]. Therefore, the transition to an educational framework that can adapt to the ongoing changes is crucial for the long-term success of global medical education. Table 1 highlights the pros and cons of the current medical education system based on the implementation process and the hurdles encountered.

Table 1 Pros  and cons of the current medical education system based on the implementation process and hurdles encountered [11, 31]
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Competency-Based Medical Education (CBME)

Rationale

CBME was conceived with the idea that the attainment of competency is an individual process for each trainee rather than a process based on the assumption that all trainees will progress at the same speed as in the current time-based training paradigm [32]. It is foreseeable that some trainees will master all the necessary skills to achieve the desired outcome sooner than they would in the currently required years of training [32]. Hence, CBME introduces a new paradigm of competence for medical training focused on outcomes, which the current format may not always address. [33]. The CBME system would allow trainees to progress through the educational process at different rates, and increased emphasis will be given to ongoing longitudinal assessment. This longitudinal assessment will enable faculty members to develop a more accurate learning timeline for the trainees, as well as to help trainees through frequent feedback and coaching, and provide the ability to make adjustments to the learning milestones as needed [33,34,35]. Thus, CBME promises greater flexibility, accountability, and learner-centeredness.

History

Competency-based education (CBE) has been adopted across multiple professions. Although CBE was proposed in medicine nearly 60 years ago, it is only in recent years that we have seen a renewed interest in CBE [12]. Several countries have reported their efforts in incorporating competency-based training and evaluation of graduates, postgraduates, and practicing physicians in the 1980s and 1990s [11]. With the introduction of the CanMEDS framework (Canadian Medical Education Directives for Specialists) project in the 1900s [36], the ACGME (Accreditation Council for Graduate Medical Education in the USA) Outcome Project in 2001 [37], the Scottish Doctor project in 2004 [38], and the MCI “Vision 2015” document in 2011 [39], CBME has become a dominant platform for postgraduate medical education. Important medical regulatory bodies have also embraced it in several countries, such as the ACGME in the USA [37, 40], both the Royal College of Physicians and Surgeons of Canada [36] and the College of Family Physicians of Canada [41] in Canada, MCI (now NMC) in India [42, 43], accrediting and/or licensing bodies in Scotland [38], the Netherland [44], and Australia [45]. As a result of the paradigm shift from the time-based method used in the current education system, CBME has been referred to as the “Flexnerian revolution of the 21st century” [11]. However, the CBME movement has met with criticism due to varying interpretations of what it is and how it is applied [32].

Core Components of the CBME System

In recent years, with the increasing adoption of the CBME framework in healthcare programs, inconsistencies have arisen in the implementation process of CBME, mainly due to the lack of understanding of what constitutes a true competency-based program or an incomplete process of implementation [11, 46]. This misled some programs to believe that CBME failed to meet the expectations [46, 47]. In response to this concern, Van Melle et al. used a two-step method to identify the five essential components for effective implementation of CBME: outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment [46]. Accrediting bodies in different countries have adopted core principles to meet their local needs [46]. For example, the ACGME and the American Board of Medical Specialties (ABMS) in the USA formally approved the six core principles of competencies, namely, patient care and procedural skills, medical knowledge, professionalism, interpersonal and communication skills, practice-based and improvement, and system-based practice [48]. The goal and assessment methods of the ACGME’s CBME six core competencies are provided in Table 2. The CanMEDS Competency Framework of the Royal College of Physicians and Surgeons of Canada specifies seven roles of a specialist, namely, medical expert, communicator, collaborator, leader, health advocate, scholar, and professional [50]. The Good Medical Practice standard in the UK GMC defines medical graduate outcomes pertaining to the doctor as a scholar and scientist, a practitioner, and a professional [51]. MCI (now NMC) specifies the expected competencies of an Indian Medical Graduate as a clinician, a leader and a member of the healthcare team and system, a communicator, a lifelong learner, and a professional (Table 3) [42].

Table 2 ACGME’s CBME six core competencies and common assessment methods [48, 49]
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Table 3 Competencies expected of an Indian Medical Graduate [42]
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Pros and Cons of the CBME System Based on the Implementation Process and Hurdles Encountered

As an increasing number of medical education programs shifted from the time-based framework to the CBME model of education across the globe, educators and program leaders were placed in an unprecedented position to learn about CBME implementation and evaluate its outcomes [46]. Focusing on the core components of CBME and addressing questions about the connection between CBME program activities and outcomes are critical to ensure that education can be connected to healthcare practice or patient outcomes [52]. Therefore, the successful implementation of CBME curricula will require a change in the organizational structure of training programs so that new curricula and assessment methods can be delivered. In addition, the teaching and evaluation process needs to be modified to support the underlying principles of CBME [52].

A well-implemented CBME curriculum will create a new paradigm of competency based on outcomes rather than on time-based training and, in essence, promote learner-centered curricula [12]. CBME system will provide educational continuity from undergraduate trainees to practicing physicians and will be advantageous to trainees and supervisors [53]. However, advances in implementing CBME curricula in the predefined time-based paradigms have been hindered by inertia, lack of resources, and a myriad of implementation challenges, including those associated with the assessment of competency, accreditation/regulation, and logistical considerations [54, 55]. For example, managing a cohort of trainees, wherein each progress at a different pace, will be a significant logistical challenge. The arrangement of necessary educational and technological solutions for the new training paradigm will also be challenging [53,54,55]. For example, a natural disaster such as the COVID-19 pandemic seriously disrupted medical education at all levels and hampered the ongoing transition to CBME [56]. Therefore, acceptance of CBME as a new educational paradigm will not come without a cultural shift across the continuum of medical education. This needs a robust and multifaceted assessment system that will require alignment with stakeholders, increased participation from faculty and staff, new educational technologies, and adequate resources [53,54,55,56]. Table 4 highlights the pros and cons of the CBME system based on the implementation process and the hurdles encountered.

Table 4 Pros and cons of the CBME system based on the implementation process and hurdles encountered [12, 53,54,55,56]
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Current Medical Education System Versus the CBME System Based on the Implementation Process and Hurdles Encountered

The current education system is a fixed time-based hierarchical teacher-centered process focusing on knowledge acquisition, sporadic subjective assessment, and a final summative assessment at the end of the training [11]. The system has been in practice globally for over a century, is well integrated into the healthcare system, and has served the needs of the community well [10]. Although the current time-based framework has worked well, in recent years, leaders have proposed reforming the system to a more flexible competency-based education framework that can adapt to the changing needs of society [12, 33]. Key reasons for the movement to replace the current education system with the CBME model are (i) calls for greater physician accountability and responsibility and a greater focus on outcomes [12]; (ii) the need to reduce unacceptable variability in graduate abilities after medical training [57, 58]; (iii) evidence that some graduates are inadequately prepared to commence graduate medical training, fellowship programs, and unsupervised practice [59,60,61]; (iv) concerns that the current education model does not have a standardized method of assessment for competency [62]; (v) the need for a medical education that can readily adapt to the changing needs [62]; and (vi) the call for improved quality of care [62]. With this reform movement, an increasing number of educational bodies are transitioning to the CBME framework, and it is quickly emerging as a new direction for accreditation standards [41, 42, 44, 45, 48, 49, 63, 64].

CBME is an outcome-based non-hierarchical process where both teacher and student are responsible for the content and learning path. CBME focuses on knowledge application and continuous objective assessments and is a time variable [11]. CBME curriculum is leaner-centered and allows trainees to achieve competency in variable periods [11]. However, CBME faces significant logistical challenges during implementation [12]. Table 5 highlights the comparison between the current medical education system and the CBME system based on the implementation process and the hurdles encountered.

Table 5 Current medical education system versus the CBME system based on the implementation process and hurdles encountered [10, 11]
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Relevancy of the CBME Framework in the Education of Future Surgical Oncologists

The demand for an adequately trained surgical oncology workforce to tackle the rising global cancer burden cannot be understated [3]. A surgical oncologist is a well-qualified surgeon who has obtained oncology training and expertise in the multidisciplinary approach to the prevention, diagnosis, treatment, reconstruction, and rehabilitation of cancer patients and devotes a significant portion of their professional practice to these activities and cancer research [65]. Surgical oncologists interact with other oncology specialists as part of the interdisciplinary collaboration in the treatment plan for cancer patients and incorporate advances in oncology management [6]. Hence, to become adept in all treatment domains of oncology, surgical oncologists require formal training pathways and sustainable certification processes [7].

Although informal training in surgical oncology goes well back to the early twentieth century, in the late 1970s and 1980s, many countries formally started to recognize surgical oncology as a specialty. In 1977, India formally recognized surgical oncology as a specialty with the formation of the Indian Association of Surgical Oncology (IASO), and structured surgical oncology training courses were started in 1989 by the MCI (now NMC) [66]. In the USA, the first surgical oncology fellowships were approved in 1983 under the supervision of the Society of Surgical Oncology (SSO) [67]. This was followed by the American Board of Surgery, the American Board of Medical Specialties, and the ACGME Resident Review Committee in Surgery (ACGME RRC-S) approval of the Complex General Surgical Oncology (CGSO) fellowship training program with 2-year subspecialty certification by 2012 [68]. Several countries, including Canada, the UK, and Brazil, also have formal surgical oncology programs [7, 69, 70]. However, considerable variations exist in the training of surgical oncologists globally, and in many countries, surgical oncology has yet to be a clearly defined specialty [6, 7].

In 2016, the Society of Surgical Oncology (SSO) and the European Society of Surgical Oncology (ESSO), two important global communities of cancer surgeons, co-published two articles to address the existing global disparities in the training paradigms of surgical oncologists [8, 9]. These articles analyzed the variations in the training programs from all six WHO geographic regions (African regions, Americas regions, Eastern Mediterranean region, Southeast Asia region, European region, and Western Pacific region) and highlighted the total training length in years offered for training surgical oncologists is long and ranges from 8 to >17 years [8, 9]. The articles also raised concerns about the lack of uniformity in training, certification, and maintenance of competency in the global surgical oncology educational paradigm [8, 9]. Therefore, it was concluded that the availability of a globally accepted gold standard curriculum for surgical oncology training that provides a broad and uniform set of guidelines for surgical oncology training standards could initiate the process of addressing these global disparities [8, 9].

To address the concerns of global disparities in the training paradigms of surgical oncologists, SSO and ESSO developed a curriculum with a broad and uniform set of guidelines on the training and maintenance of competencies for surgical oncology professionals, which can be tailored to the needs of different regions of the world [71, 72]. The curriculum incorporated the required domains considered essential in training a surgical oncologist. In addition, the curriculum introduced essential training in core competencies such as holistic patient care, medical knowledge, professionalism, inter-professional team working and communication skills, experiential learning, system-based practice, operative skills for surgical professionals, and understanding of the human/compassionate side of medicine applicable to all socioeconomic and diverse cultural regions of the world [71, 72]. This curriculum will help in providing a flexible and foundational scaffolding for training surgical oncologists globally, and individual countries can tailor the curriculum to meet local needs [71, 72]. For example, for countries with a physician shortage, it will be desirable to shorten training programs following a concise and innovative program that adheres to established competency metrics [7]. Therefore, based on this global curriculum, an emphasis on the outcome-based competency training framework tailored to the local needs and trainee’s competencies status rather than the current fixed time-based system will shorten the certification timeline for competent surgical oncologists. This approach will increase the volume of the surgical workforce without compromising the quality of care and physician competency. Moreover, a well-implemented CBME-based training framework will provide educational continuity from undergraduate trainees to practicing physicians [53] and support the broad schema of the training pathway for a career in surgical oncology introduced in the global curriculum developed by SSO and ESSO [71, 72].

Future Directions

Many countries have started transitioning toward a competency-based curriculum to meet the challenges of exponential growth in medical knowledge, technological advances in medicine, changing social and cultural issues, and healthcare reform [31]. This curriculum is a learner-centered outcome-based framework, and trainees are assessed using an ongoing longitudinal assessment enabling faculty members to develop more accurate developmental progress of the trainees [33,34,35]. However, successful implementation of the global CBME framework for undergraduate education, medical school, postgraduate education, and continuing education globally will not be achieved without significant challenges. These challenges include uncertainty surrounding the benefits of the CBME framework, inertia, lack of resources, and a myriad of implementation challenges associated with competency assessment and accreditation/regulation. In addition, logistical considerations have hindered the advancement in implementing CBME curricula [54, 55]. Therefore, an innovative approach to the design and implementation of the CBME framework to ensure that it produces a competent physician that meets the local needs would be crucial for its successful integration. An approach is implementing the CBME framework tailored to the need of specific regions and circumstances in a phased manner. This can start with the implementation of a hybrid curriculum consisting of the current time-based paradigm and the CBME with a gradual transition to the CBME curriculum. This would ensure that the stakeholders are not overwhelmed by a sudden change while providing an opportunity to measure and analyze the benefits of CBME.

Implementing the CMBE curriculum in a phased approach for training surgical oncologists would be crucial in the continued training of outstanding future oncologists to meet the increasing global demand for the surgical workforce. Moreover, cancer care has become increasingly complex due to the emergence of new diagnostic and treatment strategies, and delivery of optimal cancer care to patients requires quality surgical care and leaders in surgical oncology [73]. Therefore, develo** a global competency-based curriculum tailored to the local needs to train talented and competent surgical oncologists will increase the volume of the surgical workforce without compromising the quality of care.

Conclusion

The availability of adequately trained surgical oncologists is critical to meet the increasing demand for the surgical workforce for global cancer care. However, globally, the total length of the surgical oncology training program is long and considerable variations exist in the educational curriculum. Develo** a globally accepted gold standard curriculum for surgical oncology training based on the CBME framework tailored to local needs will ease the burden of the rising demand for the global surgical oncologist workforce. However, successful implementation of the global CBME-based surgical oncology training curriculum requires an innovative approach to ensure that this framework produces a competent surgical oncologist that meets the local needs. Therefore, a holistic approach with participation from regulatory and government educational stakeholders is paramount in develo** successful global surgical oncology training programs to help produce competent oncologists that can provide optimal cancer surgical care.