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successful patient outcomes or, more directly, by the effective completion of directly
observed surgical tasks in real or simulated settings [ 23 ].
In a complex world ruled by uncertainty, however, consistency is difficult to
achieve; patients’ anatomy differs, care teams turn over, technology changes, and
procedures can dramatically and unexpectedly intensify in the blink of an eye.
Expert surgeons distinguish themselves by confronting this uncertainty— proactively
ordering and prioritizing tasks to mitigate risk and managing distractions, thereby
creating the conditions for staying calm under pressure [ 37 ]. Like King Arthur bran-
dishing the sword he drew from stone, surgical experts challenge uncertainty with a
firm grasp on their capabilities and limitations, slowing down and intensifying their
focus in response to prevailing conditions and knowing when to seek help, if
necessary [ 44 – 46 ]. Their expert judgment comprises a cycle of information seek-
ing, critical evaluation, and course correction, as needed, making them responsive
to the inconsistency inherent in surgery and able to maintain superior performance
and positive outcomes [ 17 , 46 ]).
Surgical expertise, then, comprises not only a demonstrated level of performance
but a way of thinking—a way of approaching a complex, high-stakes endeavor
whose defining characteristic is uncertainty so as to continue growing and achieve
positive results consistently. Beyond this, formal competency standards for surgical
trainees cover a range of capability much broader than technical knowledge and
skill [ 1 ], to include interpersonal skill and professional attitudes, values, and behav-
iors. These standards, reflecting evolving notions of medical competency [ 17 , 31 ,
42 , 56 ], reveal that surgical expertise is now viewed as much as a social achieve-
ment as it is a technical one (e.g., [ 9 , 15 , 32 , 53 ]). That is, expert surgeons are rec-
ognized not only by what they can do and how they do it but also the kind of
practitioner they are and how they fit within their professional community.
The Journey Inward
No quest can be completed without a journey, the series of trials the protagonist
must endure to achieve his aims. The quest for surgical expertise is no different,
requiring approximately 10 years of “intense involvement” in surgical skill acquisi-
tion, including thousands of operations ([ 22 ], p. 114). Intense involvement com-
prises long-term engagement in deliberate practice—continuous, motivated
engagement in clearly defined tasks with performance feedback and opportunities
to repeat, refine, and improve [ 24 ]. However, although the notion of “practice makes
perfect” would seem to apply naturally to surgical learning, this is not the whole
story. The protagonist’s journey is never solitary; his path is shaped by his interac-
tions with the story’s other characters.
In the surgical learning context, interactions with other members of the care team
are essential to determining trainees’ access to practice opportunities, the degree of
challenge they experience, and the support and feedback they receive [ 20 , 25 ]. All
of these things influence trainees’ participation in work and the learning they derive
from it [ 8 , 21 ]. In addition, trainees’ observations of their role models provide
A.T. Cianciolo and J. Blessman