Since the turn of the millennium, competency-based medical education (CBME) has emerged as the standard for surgical training in the United States and many Western countries. CBME emphasizes a learner-centered approach that focuses on the achievement of specialty specific knowledge, skills, attitudes, and performance within a competency-based outcome framework. Individual competencies are specialty-specific and defined by educational governing bodies for our patients, society, and the health care system. In the United States, surgical competencies include patient care, medical knowledge, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement.

A CBME curricula relies heavily on a framework of competency-based assessments (CBAs) throughout the learning process. This includes direct observation with timely feedback, deliberate practice and coaching, appropriate levels of supervision and mentorship, graduated autonomy and entrustment, and a framework for systematic formative and summative assessments of a trainees’ educational and clinical outcomes. Milestones, workplace-based assessments (WBAs), and entrustable professional activities (EPAs) are commonly used to evaluate learners’ progress and readiness for independent practice. The goal of CBME is to produce competent physicians and surgeons who can successfully enter unsupervised practice and meet the evolving needs of the patients and population they serve [1]. By aligning surgical education with desired outcomes of surgical specialty practice, CBME aims to prepare trainees for high-quality health care delivery, patient safety, and overall health care system performance [2].

This article provides an overview of key foundational concepts related to competency assessment in surgery in the era of CBME. Beginning with an historical overview, definitions and rationales for the adoption of differing assessment frameworks for surgical training and competency assessment in the United States are provided. The strengths of CBA, such as its emphasis on assessment for learning; what a trainee does; and importance of coaching, are examined, along with CBA drawbacks, including the challenges of faculty development; resistance to change; resource allocation; and standardization. Finally, this review underscores the transformative potential of CBAs in surgical education and calls for further exploration, research, and collaborative efforts to drive future utility in the CBME arena.