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or standards. Like any apprenticeship, learning was heavily restricted to what the
trainee could directly observe, and progress and innovation were difficult.
Beginning in the early twentieth century, surgical training in the United States
began to acquire structure. As medical education reform was shaped by William
Osler, the Flexner Report of 1910 and the American Medical Association (AMA),
William Halsted laid the groundwork for our modern surgical residencies with the
triad of research, basic science knowledge, and graduated patient responsibility.
From the time of its inception in 1913, the American College of Surgeons (ACS) has
played a vital role in developing, maintaining, and refining surgical standards. The
AMA published the “Essentials of Approved Residencies and Fellowships” in 1928,
and shortly after in 1939, the ACS issued their first Fundamental Requirements for
Graduate Training in Surgery [ 1 ].
As the medical care delivery and payment continued to evolve throughout the
twentieth century, so too did medical education oversight, and in 1981 the ACGME
was formed to create a unifying force over the various medical specialty and sub-
specialty resident review committees. The medical education landscape has changed
dramatically over the last 20 years with duty hour restrictions, the Next Accreditation
System (NAS), and the current Milestones project. For surgical specialties, greater
emphasis has been put on demonstration of competence including progression of
skill in the operating room. The actual task of teaching in the operating room each
day however is still remarkably similar to the old apprenticeship model. Residents
and fellows participate in surgical cases with varying degrees of autonomy and
oversight from their mentors often with minimal structured feedback to know spe-
cifically what they did well and what needs improvement. Summative, infrequent
evaluations, which are still the basis for ACGME review, do little to foster the kind
of continual improvement cycle needed to guide trainees through the most critical
time in the development of their surgical skills. Fortunately, the last several decades
have also seen an increase in psychological research and technological advances
that can be used to make the most of time spent educating in the operating room.
The Case for Better Teaching in the Operating Room
Some may think the old adage “if it isn’t broken, don’t fix it” may apply to operative
training. After all modern medicine, including surgical medicine, has seen many
great achievements, and surgeons who complete years of training want to think they
are adequately prepared. There are however several factors that highlight the need
to continuously assess and improve our teaching in the operating room.
While the amount of medical knowledge and number and complexity of surgical
cases has increased across all disciplines, time pressure on learners, particularly
residents, has also increased. The most obvious of these pressures is the restriction
of resident duty hours. While this limitation affects residents in all specialties, it is
felt most acutely in surgical disciplines in which textbooks, didactics, or simulation
cannot wholly take the place of real operative experience. Several recent studies
illustrate this effect on current surgical residencies. Surgical residents completing
M. Mirza and J.F. Koenig