• graduate medical education
• healthcare outcomes
• resident selection

Medical education is strictly regulated in the USA according to the ‘American standards’, conforming to the local culture of comfort and convenience. Undergraduate (UGME), graduate medical education (GME) as well as general healthcare practice is easier as the system is well structured, career paths customized, clinical documentation electronically templated, academic efforts highly encouraged, trainees’ welfare upheld as a priority and financial remunerations disproportionately higher. Given recent reports of further customizing and, more likely, shrinking training time is daunting as healthcare outcomes in the USA remain substandard, inefficient and cost-ineffective and the metrics to measure those outcomes are yet to be clearly defined.1 2 The problem is further compounded by the fact that patient outcomes may not always correlate with skills and competence acquired during residency training, specifically surgical technical skills.3

Only the strong horses make it until the end—efficient, intelligent and productive. Hence, the recruitment of a robustly selected and diverse workforce is an important step towards building a strong healthcare structure. In comparison with other GME structures in the world, the ‘spongy’ US training system is inherently designed to potentially absorb each residency applicant from around the world that fulfills the basic selection criteria, one that does not include a robust ‘real-time test of clinical skills’. Assessments are either subjective or objective. The former ranges from medical school EPAs (Entrustable Professional Activities) through to core competencies of the American College of Graduate Medical Education (ACGME), responsible for nurturing competent clinicians expected to render patient care in an unsupervised manner. These evaluations carry significant potential for human bias, being entirely subjective in nature. The objective assessments for recruitment into the US GME are composed of instantaneous, computer-based tests and remain a common modality to assess a clinician’s competence—from the United States …