Leveraging simulation to support competency-based surgical training

Context: Simulation-enhanced education (SEE) has evolved from a supplementary activity into an evidence-supported cornerstone of medical education, yet in most surgical training programs it remains confined to formative use with little influence on high-stakes progression decisions. This disconnect limits SEE's contribution to patient safety, particularly at transition points where residents assume greater clinical autonomy. Issue: High-stakes decisions about readiness for autonomy in surgery continue to rely primarily on workplace-based assessments, which are vulnerable to bias, impression management, and limited opportunities for granular technical observation. This reliance introduces variability into autonomy decisions and latent patient safety risk, despite robust evidence that simulation-based assessment can reliably differentiate performance across the training continuum, while competency frameworks such as CanMEDS offer limited guidance on mandatory assessment mechanisms at high-stakes transition points. Approach: Using surgical training in the Republic of Ireland as a primary case, this article examines how national policy levers, funding arrangements, and institutional leadership can reposition SEE and simulation-based assessment as consequential components of training governance. In Ireland, service-level agreements, strategic investment by the Royal College of Surgeons in Ireland, and protected training time have enabled integration of summative simulation-based assessment into an 8-year surgical training scheme, with scores contributing directly to progression alongside established portfolio elements, illustrating design principles that are transferable across specialties and jurisdictions. Implications: The article argues that the next developmental step is the introduction of specialty-specific autonomy thresholds, framed as entrustable professional activities and substantiated through simulation-based assessment at defined progression points. Such mandatory, simulation-anchored checkpoints would align assessment practice with patient safety priorities and competency-based progression, repositioning SEE from a source of isolated validity evidence to an integrated safeguard at the point where autonomy decisions carry the greatest clinical consequence.