10
to “fit in” by seeking learning opportunities, improving their technical skill, making
themselves useful, observing others, and internalizing the values, attitudes, and
behaviors of the profession [ 8 , 32 , 40 ]. Educators may enhance trainees’ ability to
self-develop by orienting them to their role and community expectations, fostering
a positive learning climate, collaboratively setting clear learning objectives, and
conducting goal-driven observation and feedback [ 21 , 40 ].
Several chapters in this volume provide detailed guidance for designing, imple-
menting, and evaluating educational approaches consistent with the general implica-
tions described above. However, an important but easily overlooked moral of our story
is this: one cannot assume that specific prescriptions for surgical education will
achieve the same performance outcomes across settings or even across time within the
same setting [ 52 ]. The surgical learning context is always changing, and the imple-
mentation of workplace curricula in practice often is influenced by factors that educa-
tional designers did not anticipate or cannot control [ 8 , 48 ]. For example, a training
program’s assessment culture can shape trainees’ approach to learning in ways that do
not conform to expectations or produce improved clinical performance [ 2 , 43 ].
Moreover, the direct observation and feedback central to meaningful performance
assessment and deliberate practice are practically nonexistent in the clinical work-
place [ 14 , 27 , 50 , 60 ], and major reforms in medical education cannot take place until
they are [ 28 ]. Trainees, however, do observe closely [ 8 , 32 ], and they may accept as
normal the interpersonal conflict and professional silos they witness, despite official
statements labeling such values, attitudes, and behaviors undesirable [ 39 ].
Epilogue
To conclude, the story of how surgical trainees develop does not have an ending;
there will always be questions to ask and new understanding and implications that
emerge from applying the answers to education. Consistently achieving desired per-
formance outcomes requires periodically reconsidering what we are trying to
accomplish and making refinements both to our interventions and to the setting in
which they are situated [ 26 , 52 ]. It is essential that people intrigued by surgical
learning continue to ask “Why?” and “What’s going on here?” so as to continually
deepen understanding about surgeons’ development and support efforts to design
education that works. The reader may find it interesting to learn that surgical educa-
tion has become a field of study in its own right, with its own specialized degree
programs [ 34 ], which indicates the depth and breadth of knowledge about surgical
learning that has been developed to date.
Ultimately, knowledge about surgical learning is given meaning by its impact on
surgical performance [ 48 ], an endeavor greatly facilitated by educators themselves
using theory to try something new, taking a close look at what happens, and sharing
detailed stories about what they see [ 17 ]. Participatory action research is a mode of
theory development that features educators at the very center of inquiry, using a
cycle of data collection, reflection, and action to build knowledge about how people
learn in a given setting [ 4 ]. Practically speaking, this knowledge helps educators
A.T. Cianciolo and J. Blessman