8
and formal regulations dictated her level and type of direct involvement in surgical
work. For example, her procedural practice with real patients as a medical student
was limited to observing passively, gaining a feel for anatomy and pathology, holding
retractors, and occasional suturing, with more intensive hands-on practice of
procedures occurring in the skills lab [ 10 , 40 ]. As she moved inward in the community,
constraints on her practice with real patients lifted, with trips to the skills lab
becoming less frequent and involvement in simulations increasing as the scope of her
responsibility broadened to teams and more advanced technologies. Supervisors,
care team members, peers, and patients offered formal and informal learning
opportunities and feedback along the way, enhancing her ability to meet meaningful
work challenges and increasing her confidence, motivation, and commitment to
participation [ 21 ]. Importantly, she influenced these gatekeepers by proactively
seeking learning opportunities, demonstrating her motivation and capability to
improve, and gradually assuming of the mantle of community member [ 32 , 41 , 61 ].
The reader should be cautioned that in today’s rapidly changing surgical work-
place, a single-journey story is a convenient oversimplification [ 26 ]; sequels and
spin-offs are needed to accurately characterize how surgeons progress to the center
of multiple parallel communities of clinical practice, crossing the boundaries
between them in order to maintain a coherent but flexible sense of themselves as a
professional [ 9 ]. To take the science-fiction feel a step further, one could also con-
sider how learning to use surgical technology grants trainees special access to the
inner circle by enabling them to participate in the community’s definitive work [ 55 ],
much as gaining control of the “force” is necessary to being a member of the Jedi
Order in the fictional Star Wars series. Using a more grounded example, it is inter-
esting to contemplate how laparoscopic instruments and minimally invasive tech-
niques mediate perceptions of the body—once directly seen and felt, anatomy is
visualized through 2- and 3D displays—such that the surgeon controls what the rest
of the team sees [ 49 ]. This unique perceptual capability signals her status as sur-
geon, further distinguishing her from other team members and the less experienced
trainees who look on.
The Moral of Our Story: Implications for Surgical Education
At this point in our story, the practically minded reader is likely asking the question
of greatest interest to busy educators: How is all this going to help me improve edu-
cation now? [ 48 ] A key lesson we can take away from thoughtfully considering the
surgical learning context, the quest for surgical expertise, and the journey into com-
munities of clinical practice is that theory calls us to rethink what surgical learning
is. Rather than taking it to be the acquisition of technical knowledge and skills by a
lone physician in isolation, we can think of learning instead as participation in the
surgical profession in all of its technical, personal, and social respects [ 38 , 42 , 59 ].
Another key lesson is that learning and practice happen simultaneously in the teach-
ing hospital and, in so doing, require the workplace to be structured and organized
A.T. Cianciolo and J. Blessman