9in a way that supports both endeavors [ 8 , 21 , 33 ]. Viewing trainee development in
this way has clear implications for surgical education, as itemized in Fig. 1.2.
First, even the most junior learners, medical students on their surgical clerkship,
should be viewed as having a legitimate role in the workplace [ 8 , 21 , 42 ]. Legitimacy
occurs when community members—educators, peers, and other healthcare
providers—recognize and facilitate all trainees’ capacity to demonstrate “total dedi-
cation” to patients, learning, and the profession [ 62 ]. Specifically, trainees should be
included in meaningful clinical work that is appropriately challenging and that
involves interaction with—and implicit learning from—the whole of the clinical
team and patients [ 8 , 18 , 21 ]. In addition, allocation of work and dedicated learning
opportunities outside of the clinical context, such as skills lab and simulation
exercises, should be sequenced and prioritized with learners’ deeper participation in
the workplace as the ultimate goal [ 25 ]. Lower-risk activities should precede more
consequential ones to promote both safety and learning [ 8 , 21 ]. To accelerate skill
development, a deliberate practice approach—featuring performance goals, direct
observation, feedback, and opportunities to improve—should be employed [ 10 , 23 ].
In all these things—allocating work, structuring learning, fostering deliberate
practice, and role modeling—surgical educators must act as a coach and mentor,
ensuring trainee confidence and a smooth progression from the periphery inward
[ 17 , 21 , 25 ]. Importantly, trainees also have an essential role that of figuring out how
- All trainees have a functional and valued role on the surgical team, from Day 1,
with meaningful work and an appropriate level of challenge. - Educators serve as coaches, mentors, and role models, guiding trainees’ deepened
participation in surgical work. - Roles and expectations for trainees are made clear from the outset and revisited
periodically as conditions change. - Educators and trainees continuously work collaboratively to set and monitor progress
toward learning objectives. - Trainees signal readiness to deepen participation through making themselves useful
and internalizing the values, attitudes, and behaviors of the profession. - Trainees learn in teams with attendings, peers, and other healthcare providers to
promote implicit learning and enculturation. - On-the-job training is supplemented with external learning opportunities
designed to improve consequential work performance via lower-stakes practice. - On-the-job and supplemental education are interleaved to maximize training
efficiency and promote deepened participation in surgical work. - Supplemental skills training employs a deliberate practice approach.
- Specific approaches to training are continuously examined to ensure that they are
working as expected and adapted as needed. - The workplace community of clinical practice espouses the same standards and ideals
against which trainees are evaluated. - Experiences with training are shared among educators within and across institutions
to promote continuous educational quality improvement and learning about how
surgeons learn.
Fig. 1.2 Educational implications of how surgeons learn
1 “See One, Do One, Teach One?” A Story of How Surgeons Learn