Medical education and certification across the globe have evolved significantly, but disparities in the assessment of specialists in surgery and anesthesiology still persist. This paper highlights the increasing need for standardized evaluation frameworks to ensure specialists meet consistent competency levels, ensuring patient safety and enhancing professional mobility. Despite advancements, many regions still rely on outdated assessment methods that may not adequately reflect real-world clinical skills. The paper explores the differences in certification systems, focusing on competency-based evaluation and the critical role of structured assessments such as Objective Structured Clinical Examinations (OSCEs) and simulation-based tools. Moreover, it identifies the barriers hindering the full implementation of international standards and proposes strategies to bridge these gaps through global collaboration and investment in simulation infrastructure, AI, and competency-based assessments. Ultimately, a standardized global framework is recommended to improve patient care and professional practice on an international scale.

Keywords: specialist evaluation, medical assessment, OSCE, ECOE

ABA, american board of anesthesiology; ABS, american board of surgery; ACGME, accreditation council for graduate medical education; AI, artificial intelligence; ANZCA, australian and new zealand college of anesthetists; CBD, competence by design; CST, core surgical training ; DOPS, direct observation of procedural skills; EBS, european board of surgery; EBS, european board of surgery; EPAs, entrustable professional activities; ESAIC, european society of anesthesiology and intensive care; EU, europan union; FRCS, fellowship examinations royal college of surgeons; LMIC, low and middle-income; OSCE, objective structured clinical examination; RCoA, royal college of anesthetists; RCPSC, royal college of physicians and surgeons of Canada; RCS, royal college of surgeons; UK, united kingdom; WFME, world federation for medical education; WHO, world health organization

The global landscape of medical education and certification has evolved significantly over the past few decades, yet disparities in the assessment of specialists in surgery and anesthesiology persist across different countries and regions. In an era of globalization, the need for standardized evaluation frameworks is increasingly recognized to ensure that specialists meet consistent competency levels, keep patient safety, and enhance professional mobility. While some countries follow rigorous competency-based assessment models, others continue to rely on outdated examination formats that may not adequately reflect real-world clinical skills.¹

The variability in specialist certification systems

Specialist certification varies widely across countries, leading to inconsistencies in the quality of surgical and anesthesiology training. For instance, the Accreditation Council for Graduate Medical Education (ACGME) in the United States has implemented a competency-based framework that includes milestones, workplace-based assessments, and Objective Structured Clinical Examinations (OSCEs). This model contrasts with systems in Latin America and some parts of Asia, where certification often relies solely on written examinations without direct assessment of practical competencies.

In Europe, the European Board of Surgery (EBS) and the Royal College of Surgeons (RCS) have developed structured Fellowship Examinations (FRCS) and European Board Certifications to ensure harmonized surgical education across member states. However, countries without mandatory European board recognition still show heterogeneity in surgical competency assessment, leading to variable patient outcomes.

A prime example of these disparities can be seen in anesthesia training. In the United Kingdom, the Royal College of Anesthetists (RCoA) mandates multiple levels of assessment, including written, clinical, and workplace-based evaluations.² Conversely, in developing nations, anesthesia certification is often obtained solely through written or oral exams, which fail to assess crucial skills such as crisis management, advanced airway techniques, or intraoperative decision-making.³

The impact of variability on patient safety

The World Health Organization (WHO) has consistently emphasized the need for standardized evaluation to improve patient safety in surgery and anesthesiology. In its 2019 report on Global Patient Safety, the WHO highlighted that up to 5 million deaths annually are attributable to unsafe surgical practices, many of which stem from inadequate training and assessment methods.⁴

A notable case study illustrating the consequences of non-standardized certification occurred in India, where a lack of competency-based anesthesia training contributed to increased perioperative mortality rates.⁵ In contrast, countries adopting structured assessment models, such as Canada’s Royal College of Physicians and Surgeons, have demonstrated lower rates of surgical errors and anesthesia-related complications.⁶ These findings underscore the critical role of standardized assessment in ensuring high-quality surgical and anesthesia practice worldwide.

Existing international standards for specialist evaluation

Efforts to create internationally recognized evaluation frameworks have been led by organizations such as:

1. The World Federation for Medical Education (WFME), which sets global accreditation standards for medical education and specialist training.⁷
2. The ACGME Milestones Project, which evaluates surgical and anesthesiology residents on domains such as patient care, medical knowledge, and professionalism.⁸
3. The European Board of Surgery (EBS)^9,10 (RCS), which require competency-based assessments, including OSCEs and direct observation of procedural skills (DOPS).
4. The American Board of Anesthesiology (ABA), which integrates high-fidelity simulation-based assessments into certification.¹¹

Despite these advancements, many regions have yet to implement these standards fully, leading to gaps in competency evaluation and potential risks to patient safety.

The need for a standardized global framework

Given the evidence linking structured certification with improved patient outcomes, there is an urgent need for greater international collaboration to harmonize specialist evaluation. This paper explores the existing international standards for evaluation, highlights barriers to implementation, and proposes strategies to set up global benchmarking of surgical and anesthesiology competencies. By adopting uniform evaluation criteria, medical organizations worldwide can enhance professional credibility, reduce preventable medical errors, and improve patient outcomes on a global scale.

The assessment of specialists varies significantly across different countries and medical education systems. Some nations have implemented rigorous competency-based frameworks, while others rely on traditional written examinations, creating disparities in certification, clinical preparedness, and patient safety. The following section provides an overview of existing evaluation models, highlighting key differences and their implications.

The U.S. Model: Competency-Based Assessment by the ACGME

In the United States, the Accreditation Council for Graduate Medical Education (ACGME) oversees surgical and anesthesiology training programs using a milestone-based evaluation system. Residents are assessed in six core competencies, including:

1. Patient care,
2. Medical knowledge,
3. Practice-based learning,
4. Communication skills,
5. Professionalism,
6. Systems-based practice.

The Milestones Project provides structured assessments at distinct stages of training, using Objective Structured Clinical Examinations (OSCEs), workplace-based evaluations, and multi-source feedback. In surgical training, the American Board of Surgery (ABS) requires written and oral examinations along with performance-based metrics, while in anesthesiology, the American Board of Anesthesiology (ABA) integrates high-fidelity simulation assessments to evaluate crisis management skills.

This competency-based approach has led to improved surgical ability and patient safety. A study comparing U.S. board-certified surgeons with non-certified practitioners found that certification was associated with a 21% reduction in surgical complications and a 15% reduction in mortality rates.¹²

The European system: EBS and RCS examinations

In Europe, surgical and anesthesiology specialists undergo evaluation under the European Board of Surgery (EBS) and the Royal College of Surgeons (RCS). Unlike the U.S. model, which emphasizes continuous assessment, European evaluation heavily relies on final board examinations.

Surgical training in Europe

• The Fellowship of the Royal College of Surgeons (FRCS) examination includes a written test, clinical examination, and structured oral assessment.¹³
• The European Board of Surgery (EBS) requires a logbook of cases, clinical exams, and supervisor evaluations before granting certification.⁹
• Some countries, such as Germany and France, mandate added residency duration, with six to eight years of training before board eligibility.¹⁴

A study researched the impact of a board certification system and the implementation of clinical practice guidelines for pancreatic cancer on the mortality of pancreaticoduodenectomy in Japan; and found that certified specialists had superior clinical decision-making and surgical technique proficiency.¹⁵ However, a notable limitation of this system is its limited emphasis on competency milestones, as assessments occur primarily at the end of training rather than continuously.

Anesthesia training in Europe

• The European Society of Anesthesiology and Intensive Care (ESAIC) oversees anesthesiology certification, with standardized written and practical exams across EU member states.¹⁶
• The Royal College of Anesthetists (RCoA, UK) implements a multi-tiered evaluation strategy, including OSCEs, workplace-based assessments, and a logbook of cases managed.

Middle-income countries: variable certification approaches

In middle-income countries, specialist evaluation methods are still highly heterogeneous, with certification largely dependent on written or oral board exams.

México

1. The Mexican Council of Surgery, on its website, states that the certification exam will have two phases. However, it did not provide further information on the characteristics of the exam or the sections that will be included in each phase of the test. What is assumed is that one of the phases of the exam corresponds to a knowledge exam with multiple choice questions.¹⁷
2. The National Board of Certification in Anesthesiology has been in a process of continuous improvement for two years now and has managed to standardize its measurement instruments; however, it still only offers written exams.¹⁸

Competency-based training in Canada and Australia

Canada and Australia have developed hybrid assessment models, combining European-style board exams with competency-based frameworks.

Canada

1. The Royal College of Physicians and Surgeons of Canada (RCPSC) requires surgeons and anesthesiologists to undergo Competence by Design (CBD) training, which incorporates directly observed clinical practice, case-based discussions, and OSCEs.¹⁹
2. This model emphasizes entrustable professional activities (EPAs), ensuring specialists can independently manage clinical situations before certification.

Australia

1. The Australian and New Zealand College of Anesthetists (ANZCA) mandates a multi-step assessment, including a structured oral examination, OSCEs, and clinical logbooks.²⁰

Despite the clear benefits of internationally recognized evaluation standards, significant barriers prevent the full implementation of standardized competency-based assessments in surgery and anesthesiology. These barriers include disparities in medical education systems, resistance from national medical boards, economic constraints, lack of simulation infrastructure, and sociocultural differences in clinical training. Understanding these challenges is crucial for developing workable strategies to overcome them and promote global harmonization in specialist evaluation.

Disparities in medical education systems

One of the main obstacles to standardization is the heterogeneity in training duration and curricular content across different countries. For instance:

1. In the U.S., general surgery residency lasts five years, with an optional fellowship¹
2. In the UK, training follows a two-year core surgical training (CST) program, followed by six years of higher surgical training.¹⁰
3. In Germany and France, surgical residency programs last between six and eight years, with variable competency assessments.⁹

This lack of uniformity in training duration and structure makes it difficult to set up a single international standard for evaluation.

Resistance from national medical boards and regulatory bodies

Many national medical boards resist adopting international evaluation standards due to concerns over sovereignty, local practice variations, and workforce control.

Economic and logistical constraints

Implementing structured, competency-based assessments, including OSCEs, simulation labs, and workplace-based evaluations, requires substantial financial investment. Countries with limited healthcare budgets may struggle to finance:

1. Simulation centers for surgical and anesthesia training.
2. OSCE and structured oral exam development.
3. Faculty training for competency-based assessment.

A 2020 study²¹ estimated that setting up a high-fidelity simulation center for anesthesia training costs between $500,000 and $1.5 million, which is prohibitive for low- and middle-income countries (LMICs).

The harmonization of specialist evaluation in surgery and anesthesiology requires the adoption of internationally recognized standards to ensure uniform competency, patient safety, and professional mobility. Despite barriers to standardization, several strategies can ease the implementation of global assessment frameworks, drawing from successful international models.

Harmonizing training curricula and core competencies

To ensure global equivalency in specialist training, international organizations such as the World Federation for Medical Education (WFME), the Accreditation Council for Graduate Medical Education (ACGME), the Royal College of Surgeons (RCS), and the European Board of Surgery (EBS) have emphasized the need for a standardized competency framework (1). The development of core competencies in surgery and anesthesiology should include:

1. Standardized clinical exposure and procedural requirements.
2. A competency-based training model with clearly defined milestones.
3. Global benchmarks for knowledge, skills, and professionalism.

Adopting a global milestones framework, modeled after ACGME, can ensure uniform standards across training programs worldwide.

Expanding competency-based assessments

Many countries still rely on traditional written and oral board examinations. However, competency-based assessments emphasize clinical skills, decision-making, and intraoperative performance. Strategies to improve specialist evaluation include:

1. Mandatory use of Objective Structured Clinical Examinations (OSCEs).
2. Standardized Direct Observation of Procedural Skills (DOPS).
3. Entrustable Professional Activities (EPAs) to evaluate real-world competence.

Expanding structured competency assessments globally would enhance training outcomes and ensure uniform skill evaluation.

Integrating simulation-based training into specialist certification

Simulation-based training is widely adopted in high-income countries but underutilized in low-resource settings. The World Health Organization (WHO) and WFME recommend that simulation be integrated into specialist evaluation frameworks to reduce errors and improve patient safety.⁴

Simulation training provides:

1. High-fidelity operative and anesthesia crisis scenarios.
2. Firsthand training without compromising patient safety.
3. Repetitive practice to enhance surgical and anesthetic skills.

Investing in simulation labs and training centers can help bridge competency gaps and ease global standardization.

Promoting international accreditation and cross-border recognition

To address workforce mobility and certification disparities, the WFME and WHO advocate for a globally recognized accreditation system. Proposed strategies include:

1. Mutual recognition of certification bodies (e.g., allowing ACGME, EBS, RCS, and WFSA-certified specialists to practice internationally).
2. Establishing an International Board of Surgery and Anesthesiology for unified credentialing.
3. Encouraging low- and middle-income countries to align with global training standards.

Expanding such cross-border accreditation frameworks globally can help workforce exchange and harmonized evaluation

Establishing collaborative global training networks

International collaboration between high-income and low-income countries (LMIC) is essential for:

1. Improving training quality in resource-limited settings.
2. Facilitating faculty exchange programs.
3. Providing financial and technical support for simulation labs.

Expanding such global collaborations can accelerate the adoption of international standards worldwide.

Utilizing digital and AI-based assessment tools

Advancements in AI and digital health offer new opportunities for remote and automated specialist evaluation.

Key innovations include

1. AI-powered surgical skills assessment tools (analyzing video-recorded procedures).
2. Online OSCE platforms for global certification (e.g., virtual FRCS exams).
3. Remote competency tracking using digital portfolios.

The evaluation of specialists in surgery and anesthesiology plays a crucial role in ensuring lofty standards of patient care, clinical competence, and workforce mobility. However, significant disparities persist in training curricula, assessment methods, accreditation processes, and access to competency-based evaluations across different regions. This paper has analyzed the need for internationally recognized evaluation standards, the challenges to standardization, and effective strategies for implementation.

1. Current evaluation methods vary significantly across countries, with high-income nations (e.g., U.S., Canada, UK, Australia) adopting competency-based frameworks like the ACGME Milestones Project and simulation-based assessments, while LMIC countries still rely on traditional written/oral exams.
2. Internationally recognized standards (WFME, ACGME, RCS, EBS, WHO) have improved specialist training quality, but their adoption is still inconsistent across regions.
3. Barriers to standardization include disparities in training duration, national licensing restrictions, financial constraints, limited access to simulation-based training, and sociocultural differences in surgical and anesthesiology education.
4. AI-based assessments and digital learning platforms are appearing as effective tools for remote competency evaluation, particularly in resource-limited settings.

To bridge disparities and provide a unified global framework for specialist evaluation, the following recommendations should be considered:

1. Harmonization of Training and Assessment Standards
2. Expansion of Competency-Based Evaluation Methods
3. Investment in Simulation-Based Training
4. Establishment of a Unified Global Accreditation System
5. Leveraging AI and Digital Platforms for Assessment

The standardization of specialist evaluation in surgery and anesthesiology is essential to ensuring global competency, improving patient safety, and helping workforce mobility. By harmonizing curricula, adopting competency-based assessments, investing in simulation training, promoting global accreditation, and using AI-based tools, medical institutions worldwide can work toward a unified, high-quality evaluation system.

While high-income nations have made significant advancements, many LMICs still face major barriers to implementing these standards. International collaboration, government support, and strategic investment will be critical in achieving fair and standardized specialist evaluation globally.

Future research should focus on:

• Evaluating the long-term impact of competency-based assessments on patient outcomes.
• Developing cost-effective simulation solutions for resource-limited settings.
• Assessing the role of AI in large-scale competency evaluation.

By adopting a global, standardized approach, we can ensure that every specialist—regardless of country of training—meets the highest standards of medical competence, ultimately improving patient care worldwide.

None.

The authors declare that there is no conflict of interest in authoring this article.

1. Karle H. Global Standards in medical education: evaluation and accreditation in medical education—a wfme perspective. Med Teach. 2018;3:231-235.
2. Royal College of Anaesthetists (RCoA). The anaesthesia curriculum and assessment strategy. London: RCoA; 2021.
3. Lakhtakia R, Alsuwaidi NL. Assessment as learning in medical education: feasibility and perceived impact of student-generated formative assessments. JMIR Med Educ. 2022;8(3):e35820.
4. World Health Organization. Global action on patient safety. Geneva: WHO; 2021.
5. Fishbain D, Danon YL, Nissanholz Gannot R. Accreditation systems for Postgraduate Medical Education: A comparison of five countries. Adv Health Sci Educ. 2019;24(3):503–524.
6. Cadieux M, Healy M, Petrusa E, et al. Implementation of competence by design in Canadian neurosurgery residency programs. Med Teach. 2022;44(4):380–387.
7. World Federation for Medical Education (WFME). Global Standards for Postgraduate Medical Education. 2024.
8. Edgar L, McLean S, Hogan SO, et al. The milestones guidebook. Accreditation Council for Graduate Medical Education (ACGME). 2020.
9. European Union of Medical Specialist. UEMS. 2025.
10. Royal College of Surgeons of England. Royal College of Surgeons of England. 2025.
11. The American Board of Anesthesiology. 2025.
12. Xu T, Mehta A, Park A, et al. Board certification, MOC, and surgical complications. Presented at: ABMS Conference; 2017.
13. Royal College of Surgeons of England. Royal College of Surgeons of England. 2025.
14. Drossard S. Structured surgical residency training in Germany: An overview of existing training programs in 10 surgical subspecialties. Innov Surg Sci. 2019;4(1):15–24.
15. Mizuma M, Yamamoto H, Miyata H, et al. Impact of a board certification system and implementation of clinical practice guidelines for pancreatic cancer on mortality of pancreaticoduodenectomy. Surgery Today. 2020;50:1297–1307.
16. European Society of Anaesthesiology and Intensive Care. European Society of Anaesthesiology and Intensive Care. 2025.
17. Consejo Mexicano de Cirugía General. Consejo Mexicano de Cirugía General. 2025.
18. Consejo Nacional de Certificación en Anestesiología. Consejo Nacional de Certificación en Anestesiología. 2025.
19. Royal College of Canada. Royal College of Canada. 2025.
20. Australian and New Zealand College of Anaesthetists & Faculty of Pain Medicine. ANZCA. 2025.
21. Brown WJ, Tortorella R. Hybrid medical simulation - a systemic literature review. Smart Learn Environ. 2020;7–16.