What Evidence is There for the Use of Workplace-Based Assessment in Surgical Training?

BACKGROUND: Recent years have seen broad changes in postgraduate training with a move toward structured formative and summative evaluation of trainees' competencies using workplace-based assessment (WBA) tools. The fitness for purpose of these instruments in surgery has been much debated. The aim of this study is to explore the evidence underlying the introduction and ongoing use of WBAs in surgical training. METHODS: A critical literature review was conducted to identify studies evaluating the use of WBAs in postgraduate surgical training. The search was conducted using the electronic databases Pub Med for full-text articles in English. Additional critical evaluations of the curriculum relating to WBAs were included. The articles were synthesized in a narrative review. RESULTS: The implementation of WBA requirements in surgical training has occurred despite a relative dearth of direct evidence of their efficacy and benefit. Studies and critical reviews are being regularly undertaken to ensure that supporting evidence is accrued and the drive for improvement and refinement is maintained. It is emerging that WBAs are (contrary to their current nomenclature) formative tools for feedback and hence learning. They can facilitate the progression toward expert practice at the center of the zone of proximal development and the higher levels of Miller's pyramid, but fall short owing to their focus on competence of guiding surgical trainees to the higher levels of Maslow's hierarchy. CONCLUSIONS: Limited evidence has potentially undermined the introduction of WBAs in surgical training to date. There are misunderstandings regarding their use as either summative or formative educational tools. These shortcomings are an opportunity for further work in examining WBAs in their current or modified form.