Competence is “the quality of being competent or capable of performing an allotted function” [1]. Training of physicians has always had as its primary goal, the formulation of an end product that is capable of providing safe and effective care, while recognizing that continued acquisition of knowledge and skills following the completion of the initial training period is an essential part of professionalism. It has long been accepted that the lifelong application of knowledge and practice of both the art and science of one’s chosen specialty will continually enhance and improve individual performance to the benefit of each patient.

Key Concept: Defining competence for surgical trainees is a process in evolution and extends beyond the traditional metric of case numbers and subjective assessment.

It is fair to say that the definition of competence has been elusive enough that residency training programs have been willing to declare competence of each trainee on the day that they complete their residency but no longer. Achievement of board certification has not equated to competence to practice (by the Boards’ own admission). While in some part motivated by medicolegal concerns for potential shared complicity in tort litigation on the part of training programs and program directors, the much more significant concern has been the inability to accurately and reproducibly define the parameters of competence within each medical specialty.

For colon and rectal surgery, and other technically focused specialties (be they surgical or medical), this has evolved into the application of cumulative case numbers as a presumed surrogate for technical competence. There is no question that there is an empirical value to performance of procedures, but the number alone does not adequately describe individual resident performance, with all of the subtle nuances of each individual situation for each resident. Consequently, there is a movement to define the minimal technical requirements for each individual procedure within the domain of each specialty. The ACGME has initiated the Milestone Project, which is an attempt to define specific outcomes for each specialty as defined by expert educators in the field. These data will be evaluated on an ongoing basis and will be incorporated into the new annual program reporting for each program [2]. While creative and encouraging, it should be pointed out that these outcomes are in the early stages of being defined and have not yet been demonstrated to be associated with competence. Furthermore, they are subjective evaluations of technical performance and may not be as robust as other more easily quantifiable measures such as communication, system-based performance, and practice-based learning.

Key Concept: Changes ranging from how we manage certain disease processes to the level of responsibility given to trainees has impacted general surgery training and increased the need for additional training beyond residency.

At present, all colon and rectal surgeons must be fully trained general surgeons. It is this fact that has, until recently, allowed for achievement of sufficient specialty training in one additional year of colorectal residency. General surgery has been under enormous stress to provide satisfactory training in 5 years, and this has resulted in a concerted effort to redefine the training of general surgeons. Lewis and Klingensmith have neatly and comprehensively reviewed these stresses in a recent forum at the American Surgical Association [3]. The authors outline the changes in the practice of general surgery that have occurred over the past 20 years, the net effect of which is to reduce the volume of some operations that were previously the staples of general surgical training. Of particular importance for the specialty of colon and rectal surgery is the increasing percentage of abdominal operations performed laparoscopically; this, combined with the vanishing numbers of surgical procedures for peptic ulcer disease and complex biliary tract disease, percutaneous vascular procedures, and the increasingly nonoperative management of abdominal trauma, has focused attention on complex minimally invasive colorectal procedures as necessary for training general surgeons. This, combined with the non-ACGME industry-funded postresidency fellowships in bariatrics and other advanced minimally invasive procedures (and some non-ACGME-sponsored colorectal fellowships as well), has spawned a desire on the part of the American Board of Surgery to consider a subspecialty of advanced gastrointestinal tract surgery as a way to compete with existing training paradigms.

Other issues of concern to general surgery include the fact that about 80 % of graduating general surgery residents pursue additional training beyond the basic 5-year training period, predominantly because they do not feel confident to practice independently [3] and because they believe that additional training provides a competitive advantage in the workplace [4]. Consequently, the real total duration of general surgery training is currently 6–7 years for the majority of general surgery graduates.

Finally, many factors have conspired to eliminate traditional residency concepts of graduated responsibility, both in decision making and operating. Today’s chief resident has often not been solely responsible for a decision to operate or for an unsupervised operative intervention. Some of these factors will never return to Halsteadian ideals. Perhaps there was not sufficient supervision in the past, to the patients’ detriment in some cases. However, the end result of this evolution is often a new graduate who is ill-prepared for independent function as a practicing surgeon.

Key Concept: Paradigm shifts for attending surgeons, residents, and curricula that mirror the evolving modern training environment are required to maximize educational opportunities and minimize inefficiency.

Approaches to altering the educational directions of residency training are severalfold [3]. Curriculum redesign must be undertaken to reflect changes in practice and then be treated as a dynamic and fluid situation, changing with the evolution of practice. Abandoning outdated portions of the curriculum will free up time for the resident to learn what is essential. Furthermore, there must be an acknowledgement that service demands on the part of the residents creates inefficiencies of learning that must be challenged and streamlined wherever possible. Physician extenders and other nonresident resources must be used more liberally to cover the service needs traditionally provided by residents; current and anticipated economic constraints will challenge the ability to do so, since traditionally service and education have been inexorably intertwined.

Individual self-directed learning rather than group lectures will become the norm, particularly with more stresses (and presumably further reductions) on maximum allowable work hours. Adult learning theory suggests that today’s residents are least inspired by traditional lectures and most by interactive self-directed tools. Consequently, sophisticated learning resources such as the Surgical Council on Resident Education (SCORE®) portal should be made available to all residents, as should other validated teaching vehicles. Self-assessment is essential to monitor individual resident performance, and comparisons among residents and programs will improve the value of these exercises.

There needs to be a greater focus on improving the teaching skills of surgical attendings. The old concept of “stealing the case” while not providing constructive feedback to the operating resident cannot continue. Residents need to be directed toward those procedures that will enhance their education; only devoted attendings can provide this constructive instruction. Those attending who cannot provide appropriate direction will be deleted from teaching services. Each technical interaction should be followed by a debriefing exercise, even if to say “well done in all aspects.” Regular formative evaluations must be a required part of each resident interaction.