4
to the next level [ 52 ]. One could ask, for example, why is “see one, do one, teach
one” held up as a time-honored approach to training technical skill? Are today’s
training objectives and conditions the same as in 1890, when William Halsted
founded the surgical residency on this model [ 36 ]? Considering the dizzying array
of technology in the modern operating theater, is observing a procedure once enough
for a trainee to go on and successfully perform the procedure and then teach it to
others? If the answer to this question is no [ 54 ], how many repetitions are needed
and how can they be provided in light of patient safety concerns and restricted duty
hours? What kind of repetitions “count” as practice? The Accreditation Council for
Graduate Medical Education’s recently established Next Accreditation System [ 47 ]
also has raised this question: How do we know if practice is actually making sur-
geons competent?
Theorists in medical education make it their business to ask questions. They
explore learning in all its complexity so as to enable a thoughtful, purposeful
approach to developing others [ 26 , 42 ]—an approach in which understanding and
practical solutions evolve as people share evidence and insight from grappling with
educational problems in their local setting [ 52 ]. At the program level, learning the-
ory may be used to inform decision making on training standards and policy, as well
as the adoption of educational infrastructure and technology [ 34 ]. At the individual
or team level, understanding how people learn may help surgical educators adapt
instructional and assessment strategies to best suit the needs of their trainees, their
patients, and their service. Learning theory has been used, for example, to explore
how the old “see one, do one, teach one” adage may be updated to improve learning
outcomes in the modern surgical training context [ 36 ].
Documenting all the questions that theorists have asked about learning, and the
answers they have produced, far exceeds the scope of this chapter. Instead, this chap-
ter tells a single story of how surgical trainees develop by weaving multiple theories
together. It is a story that emerges out of stepping back from the immediate, practical
tasks at hand, carefully examining all that is going on, and packaging that complex
reality into a narrative about learning that can be readily understood and shared with
others. It is a tale of how environmental conditions, supervisory methods, and trainee
characteristics cooperate to produce surgical expertise. The purpose of telling this
story is to present surgical educators inclined to ask questions with answers they can
use to enrich their thinking and to approach educational improvement with an atti-
tude of experimentation and innovation. Ideally, this story also will inspire educators
to contribute to theory as an important way of developing the next generation of
surgeons [ 8 ]. Much of this story likely will seem familiar, perhaps even obvious, like
traveling down a neatly paved road, but hopefully it also is a bit unsettling, like the
urge to follow that road around the bend to a destination not yet envisioned.
The Surgical Learning Context
Our story opens in the teaching hospital, a demanding place by any measure. Here,
trainees commonly encounter an “unfiltered immersion experience” ([ 25 ], p. 105),
where they are simultaneously learners and functional members of the surgical
A.T. Cianciolo and J. Blessman