The issue is as old as physician residency itself: Some learners are ready to graduate before others, yet the length of training is the same for everyone in a given program.
“There's been a movement toward competency-based medical education in graduate medical education [GME] for several decades. Conceptually, it’s something that a lot of people buy into, but the practical implications of moving to a competency-based system are things that people wrestle with,” said John Andrews, MD, the AMA’s vice president for GME innovations.
“They worry that it creates work, that time variability raises practical concerns about salaries, all kinds of things,” Dr. Andrews said. “So, despite the strong interest, there hasn't been a lot of movement on it—until now.”
Back in 2019, announcement of the AMA Reimagining Residency initiative spurred GME leaders at the Mass General Brigham to devise a model for competency-based, time-variable GME, termed “Promotion in Place,” that could be customized and piloted in multiple specialties. Their successful grant proposal involved further development of the model and its implementation as proof of concept and an initial outcomes assessment.
The pathology residency program at Massachusetts General Hospital launched a Promotion in Place pilot in 2020 that is ongoing. Trainees who fulfilled explicit criteria for graduation prior to the standard date were offered the option to voluntarily graduate from residency into a period dubbed “sheltered independence.” At this stage, the physicians were fully credentialed attendings within their department until what would have been their standard graduation date.
In 2024, the Mass General Brigham AMA Reimagining Residency grant extended support to a Promotion in Place pilot in the ob-gynecology residency program at Michigan Medicine, which was supported by the American Board of Obstetrics and Gynecology and the Accreditation Council for Graduate Medical Education (ACGME).
Now a Promotion in Place pilot is going national in general surgery.
This spring, with approval from the American Board of Surgery (ABS), general surgery residency programs were invited to apply to join the Promotion in Place pilot. Leaders involved in the effort expect that by January 2028 at least 30 surgical residency programs across the U.S. will be eligible to graduate qualifying trainees into a period of sheltered independence as attendings.
The Promotion in Place General Surgery implementation team will evaluate the feasibility, acceptability and outcomes of this model of competency-based, time-variable training in general surgery.
The effort is not only generating interest at the residency program level. In addition to the AMA, Promotion in Place has the endorsement and backing of organizations such as the ACGME, ABS, American College of Surgeons, American Surgical Association, and the Association of Program Directors in Surgery.
How it works
A viewpoint essay published in the American College of Surgeons Bulletin explains how the pilot program will be rolled out.
In the Promotion in Place model and competency-based, time-variable “approach, trainees become American Board of Surgery-admissible when they are deemed competent and practice ready,” wrote the article’s authors.
Trainees must meet all the board’s and ACGME’s usual requirements, except for the amount of time in training.
“Qualified trainees then voluntarily graduate early and become fully credentialed attendings with billing privileges until what would have been their standard graduation date,” the authors explained. “This structure allows the individual an independent experience serving as an attending while ‘sheltered’ in their training institution.”
Why it matters
“Autonomy is very important in surgery training,” Ronald B. Hirschl, MD, MS, FACS, one of the authors, said in an interview. “You have to have some kind of process where, once trainees are practice ready, you start to let them do it on their own. That builds confidence. It builds decision-making and judgement.”
What competency-based, time-variable education does is account for when trainees are actually ready for autonomy and independent practice.
“We tried some different models but finally settled on Promotion in Place because trainees stay in their home institutions,” he said. “They can be attendings just like they would be on July 1, but they stay in a familiar environment with their mentors.”
Assessment is essential
Dr. Andrews said the project is not as much about time variability as it is about the quality of assessment.
“The project hinges on our ability to trust our assessments that someone is competent, and that's important whether you're time variable or not,” he said. “One of the exciting things about the pilot is that if it's done in enough programs that are in enough different environments—academic medical centers, community-based programs, those kinds of things—that it really pressure-tests the feasibility of this model. And it will be important to understand what supports are necessary to move in this direction in different environments.”
Here’s how to join
Additional general surgery residency programs can apply to join the national pilot on an annual basis.
“As the pilot develops, we are intent on creating a community of centers to identify best practices, share ideas and create processes for successful implementation,” says the American College of Surgeons Bulletin viewpoint. There is a need for flexibility when applying the Promotion in Place sheltered independence “experience to each program is paramount while principles of enhanced autonomy and experience in the attending role are maintained.”
Institutions interested in participating in the pilot are encouraged to learn more about it and then email the Promotion in Place General Surgery team. Also, explore the full FAQ for the program.
