The Crisis in Surgical Training & Proficiency-Based Progression (PBP)

Guest: Professor Anthony G GallagherTopic: The Crisis in Surgical Training & Proficiency-Based Progression (PBP)Episode SummaryIn this inaugural episode, Patrick Kiely sits down with Professor Tony Gallagher — founder of Proficiency-Based Progression and one of the world's leading researchers in surgical skills assessment and simulation-based training — to examine a deeply uncomfortable truth: that professional credentialing in medicine tells us almost nothing about actual clinical competence. Tony shares 30 years of evidence challenging the assumptions underpinning surgical and procedural training worldwide, and makes the case for Proficiency-Based Progression (PBP) as the superior — and inevitable — alternative.Key Topics Covered1. The Competence Problem in Surgery — 0:00Why credentials don't equal competenceThe Halsted training paradigm — developed in the late 19th/early 20th century — and why it's still in useHow to actually find out if your surgeon is good (hint: ask the theater sister)2. Why Current Training Metrics Are Failing — 5:08Procedure volume and hours logged as proxies for competence — and why they're wrongThe misuse of Likert-type scales in surgical assessmentReduced work hours legislation (Europe/US) and its impact on trainee experienceThe Libby Zion case (New York) and how it changed US residency hours3. The Yale Study That Changed Everything — 9:53The landmark 2002 Yale study showing simulator-trained residents made 60% fewer errorsWhy it became a citation classic — and why change was still slowPublication:  Gallagher & Seymour (2002). Virtual reality training for laparoscopic surgery. Annals of Surgery, October 2002. (Presented at American Surgical Association, April 2002) https://journals.lww.com/annalsofsurgery/abstract/2002/10000/virtual_reality_training_improves_operating_room.8.aspx4. The American College of Surgeons Response — 12:29Gerry Healy's pivotal leadership shift at the Boston meetingThe establishment of Accredited Educational Institutes (2006)Why 100+ accredited simulation centers still aren't producing the training outcomes expected5. The Experience ≠ Competence Myth — 16:47Why procedure volume is a noisy surrogate for surgical skillHow some practicing consultants perform worse than residents in trainingObjective intraoperative performance assessment as the gold standard6. Proficiency-Based Progression: How It Works — 20:30The mechanics of PBP: phases, steps, errors, critical errors, and the benchmarkEstablishing benchmarks from experienced — not world-class — practitionersConstruct validity, inter-rater reliability, and why Likert scales failThe role of deliberate practice (Ericsson) and why explicit, formative feedback accelerates learningPublication: Mazzone, Elio; Puliatti, Stefano MD; Amato, Marco; Bunting, Brendan; Rocco, Bernardo; Montorsi, Francesco; Mottrie, Alexandre; Gallagher, Anthony G. PhD, DSc||. A Systematic Review and Meta-analysis on the Impact of Proficiency-based Progression Simulation Training on Performance Outcomes. Annals of Surgery 274(2):p 281-289, August 2021. | DOI: 10.1097/SLA.00000000000046507. Why PBP Hasn't Been Adopted Universally — 35:27"It's a failure of leadership"Organisations that have adopted PBP: AANA, ERUS, ORSI AcademyIncentive structures in healthcare and medical device manufacturing that slow adoptionThe Center for Medicare Services complication-rate accountability model as a potential lever8. The Economics of PBP — 37:49Publication: Puliatti, S., Rodriguez Peñaranda, N., Amato, M., De Groote, R., Farinha, R., Bunting, B., van Cleynenbreugel, B., Mottrie, A. and Gallagher, A.G. (2026), Randomised trial on the economic impact of proficiency-based progression vs conventional robotic surgical training. BJU Int, 137: 493-501. https://doi.org/10.1111/bju.70130 https://bjui-journals.onlinelibrary.wiley.com/doi/full/10.1111/bju.70130 — Cost-effectiveness analysis of PBP vs. conventional training. At 500 trainees/year: PBP ~€1.7M vs. conventional ~€3.5M; cost equivalence at just 25 trainees; 100% of PBP trainees reached proficiency vs. 58% conventional9. Surgeon Skill Predicts Patient Outcomes — 40:24PBP applied to communication skills: deteriorating patient handover study, Cork University HospitalPBP applied to epidural training: 50%+ reduction in epidural failure rates for non-PBP trained group10. PBP Beyond Medicine: The Utilities Sector — 45:42Reach Active case study: PBP training for utility workers to safely identify and excavate buried cablesOver €1 million saved in avoided utility strikes in year oneSame methodology, same results — across a non-university workforce11. How to Implement PBP in Your Organisation — 48:25Start by identifying individuals who are objectively good at the taskWork out the metrics: phases, steps, errors, critical errorsValidate — consensus, not just agreementBuild or select simulation tools around the validated metricsTrain faculty on the metrics firstRequire trainees to pass the online didactic benchmark before entering the skills labTrain to benchmark — not to time, not to hours12. AI, Robotics, and the Future of Training — 1:01:31Why AI currently measures process, not performanceWhat AI will need to assess: granular, step-level surgical actionsThe endovascular sphere as the likely first domain for AI integrationWhy simulation and AI must be seen as tools, not solutionsThe inevitability of PBP adoption — the question is only whenConnect & FollowShow Me The Evidence PodcastTony Gallagher / KU Leuven:  https://www.linkedin.com/in/anthony-g-gallagher/ Google Scholar: https://scholar.google.com/citations?hl=en&user=rNTScRMAAAAJ&view_op=list_works&sortby=pubdateTimestampsTopicTimeThe competence problem: credentials vs. skill | 0:00Why current training metrics are wrong | 5:08The 2002 Yale simulator study | 9:53ACS response and simulation center rollout | 12:29Experience ≠ competence | 16:47Proficiency-based progression — mechanics | 20:30Why PBP hasn't been widely adopted | 35:27The economics of PBP | 37:49Surgeon skill predicts patient outcomes (NEJM) | 40:24PBP in utilities / Reach Active case study | 45:42How to implement PBP in your organisation | 48:25AI, robotics, and the future of training | 1:01:31