5team. Learning occurs on the job, in full context, within a group of providers that is
hierarchical, interprofessional, and frequently changing [ 9 ]. Focused technical skill
development must fit within a mandated 80-h workweek along with clinical paper-
work, quality improvement projects, scientific research, and teaching junior peers,
which requires maximum efficiency in the face of numerous distractions and unex-
pected events [ 9 , 25 ]. Technologies used to perform procedures are constantly
evolving, changing the organization of surgical work and requiring the development
of new skill [ 9 , 49 ]. To accelerate skill acquisition, training supplements immersive
learning with skills laboratories, simulation exercises, and didactics such as grand
rounds and journal clubs [ 25 ]. Workload is high at all levels of the hierarchy; this is
a setting where learning to work fatigued during training is believed necessary to
meet the demands of future independent practice [ 16 ].
With learners on the care team, educators must balance the obligation to provide
a high volume of safe, quality care with the mission to develop trainees at all levels,
from medical student to fellow [ 32 , 51 ]. Trainees’ performance is assessed regularly
[ 29 ] using methods that range from written tests to direct observation of real or
simulated performance and assessors that range from supervisors and peers to non-
physician providers, medical students, and patients [ 58 ]. Surgical educators are held
accountable for high-risk, high-stakes outcomes, which depend not only on their
technical skill but also successful team coordination and careful regulation of train-
ees’ graded responsibility in patient care. The operating theater provides opportuni-
ties for educators and trainees to work closely together on technical skill in practice
[ 6 , 63 ], but even here the decision to entrust trainees with independent activities that
will enhance their learning depends on many factors that differ with each procedure,
trainee, and educator [ 8 , 30 , 32 , 51 ].
In sum, the surgical learning context offers opportunities for and places constraints
on trainee development that differ vastly from the classroom [ 8 , 20 , 40 ]. To support
educational decision making, theory must be able to explain how performance
improvement happens here [ 42 ]. General theories applicable to surgical education
explore what expertise looks like and the kind of practice it requires [ 5 , 19 , 24 ]. They
examine how social dynamics influence what is learned, how, when, and from whom
[ 3 , 12 , 38 , 59 ], how workplace characteristics shape learning processes [ 7 , 21 ], how
experience can be structured to promote optimal learning outcomes [ 11 , 35 ], and how
learners play an active role in their own development [ 13 , 57 , 64 ]. Theory specific to
surgical learning illustrates how this more general understanding may be extended by
asking questions about its fit to the surgical learning context.
The Quest for Surgical Expertise
The plot of our story centers on our protagonist, the trainee, who is challenged with
a quest: to become a surgical expert. To accomplish this mission, the trainee must
go beyond graduating from a series of training programs, beyond having spent years
in scrubs and operating rooms, and beyond being told by his peers that his experi-
ence makes him an expert [ 22 , 44 ]. Rather, his quest for expertise is accomplished
when he consistently exhibits superior performance, as reflected indirectly by
1 “See One, Do One, Teach One?” A Story of How Surgeons Learn