Junior medical officers in PGY1 demonstrate a broad range of competence levels for several common, practical, clinical skills, with some performing at an inadequate level. There is no relationship between their self-reported level of confidence and their formally assessed performance. This observation raises important caveats about the use of self-assessment in this group.

The MMI is a moderately reliable method of assessment. The largest source of error relates to aspects of interviewer subjectivity, suggesting interviewer training would be beneficial. Candidate performance on 1 question does not correlate strongly with performance on another question, demonstrating the importance of context specificity. The MMI needs to be sufficiently long for precise comparison for ranking purposes. We supported the validity of the MMI by showing a small positive correlation with GAMSAT section scores.

Students who report finding the operating theatre a useful experience are those who adopt active strategies to successfully manage their learning across the three domains. The paper describes curricular initiatives that have been introduced in a department of surgery to help more students make the most of their learning in theatres, and goes on to discuss the wider implications of the findings for surgical education beyond this case study.

In any particular theatre session, the way in which learning evolves or is obstructed for any student, and the shape that teaching takes, depends on the interpretations that the student and the surgeon make in 'sizing up' the teaching and learning environment. How surgeons and students interpret and respond to each others' behaviour, style, attitude and even demeanour, has consequences for the way teaching and learning develop. The concepts of legitimacy and trust underpin these interpretations and are central to understanding the processes of teaching and learning in this setting.