“They Have to Adapt to Learn”: Surgeons’ Perspectives on the Role of Procedural Variation in Surgical Education

Abstract

OBJECTIVE-Clinical research increasingly acknowledges the existence of significant procedural variation in surgical practice. This study explored surgeons' perspectives regarding the influence of intersurgeon procedural variation on the teaching and learning of surgical residents.DESIGN AND SETTING-This qualitative study used a grounded theory-based analysis of observational and interview data. Observational data were collected in 3 tertiary care teaching hospitals in Ontario, Canada. Semistructured interviews explored potential procedural variations arising during the observations and prompts from an iteratively refined guide. Ongoing data analysis refined the theoretical framework and informed data collection strategies, as prescribed by the iterative nature of grounded theory research. RESULTS-Surgeons endorsed the use of intersurgeon procedural variations to teach residents about adapting to the complexity of surgical practice and the norms of surgical culture. Surgeons suggested that residents' efforts to identify thresholds of principle and preference are crucial to professional development. Principles that emerged from the study included the following: (1) knowing what comes next, (2) choosing the right plane, (3) handling tissue appropriately, (4) recognizing the abnormal, and (5) making safe progress. Surgeons suggested that learning to follow these principles while maintaining key aspects of surgical culture, like autonomy and individuality, are important social processes in surgical education. PARTICIPANTS-OurCONCLUSIONS-Acknowledging intersurgeon variation has important implications for curriculum development and workplace-based assessment in surgical education. Adapting to intersurgeon procedural variations may foster versatility in surgical residents. However, the existence of procedural variations and their active use in surgeons' teaching raises questions about the lack of attention to this form of complexity in current workplace-based assessment strategies. CIHR Author Manuscript CIHR Author Manuscript CIHR Author ManuscriptFailure to recognize the role of such variations may threaten the implementation of competencybased medical education in surgery.

Dealing with the tension: how residents seek autonomy and participation in the workplace

“…Further implications of our results are also worth noting. Apramian and colleagues described residents’ responses to variations in surgical supervisors’ procedures and their various restrictions, their negotiation strategies when confronted with different thresholds of practice, and how they deemed such restrictions desirable in surgical training . Our study complements their findings by highlighting the reverse source of tensions arising from too much autonomy and too many opportunities to participate and how residents coped with these.…”

“…Nonetheless, scant attention has been paid to the question of how residents respond to such supervisory practices when these do not match their preferences, which could result in tensions during clinical supervision. Apramian and colleagues have described how residents must negotiate procedural variations with their supervisors, in an effort to access practice and discover their preferences and principles of practice . What they did not explore, however, is how residents decide to act on both invitational and restricted workplace affordances, and how these co‐participation practices could maximise residents’ learning opportunities.…”

“…Apramian and colleagues have described how residents must negotiate procedural variations with their supervisors, in an effort to access practice and discover their preferences and principles of practice. 17,18 What they did not explore, however, is how residents decide to act on both invitational and restricted workplace affordances, and how these coparticipation practices could maximise residents' learning opportunities. The purpose of this study is, therefore, to explore and understand tensions that residents experience during supervision, and how residents cope with them to maximise their learning opportunities.…”

The forgetting health system

“…So it is too with clinical practices. Procedural variation in surgery seems to confer versatility that allows surgeons to vary their approach, depending on the specific needs of a patient . Centres of excellence can have very good reason to do things differently to other health services, because of the different mix of patients they see, the unique resources they have, and the accumulated local evidence supporting their specialised approaches.…”

Evaluation of standardized training effect for surgery residents based on WeChat public platform

“…In surgical learning, we must not only master a wealth of theoretical knowledge, but also cultivate skilled clinical operations. Therefore, surgical teaching needs to have rich content and diverse teaching forms to meet the learning needs of students, which is di cult to achieve through traditional books and classrooms [11]. For example, the operation video is played in the classroom for auxiliary teaching, and the students sitting in the back row cannot concentrate because they cannot see the focus in the video.…”