title: "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.
  
  
  METHODS
  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.
  
  
  METHODS
  Our sample included 99 hours of observation across 45 cases with 14 surgeons. Semistructured, audio-recorded interviews (n = 14) occurred immediately following observational periods.
  
  
  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.
  
  
  CONCLUSIONS
  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. Failure to recognize the role of such variations may threaten the implementation of competency-based medical education in surgery.
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, London, Ontario, Canada. Electronic address: tavis.apramian@schulich.uwo.ca.
authors.forename: Tavis
authors.initials: T
authors.lastname: Apramian
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, London, Ontario, Canada.
authors.forename: Sayra
authors.initials: S
authors.lastname: Cristancho
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, London, Ontario, Canada.
authors.forename: Chris
authors.initials: C
authors.lastname: Watling
authors.affiliation: Department of Surgery, Schulich School of Medicine & Dentistry, London, Ontario, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Ott
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, London, Ontario, Canada.
authors.forename: Lorelei
authors.initials: L
authors.lastname: Lingard
mesh_terms: D004059:Diffusion of Innovation; D004503:Education, Medical, Graduate; D055317:Evidence-Based Practice; D013502:General Surgery / Q000193:education*; D066296:Grounded Theory; D006784:Hospitals, Teaching; D006801:Humans; D007396:Internship and Residency; D007407:Interviews as Topic; D009864:Ontario; D010818:Practice Patterns, Physicians'; D018794:Problem-Based Learning; D036301:Qualitative Research; D066231:Surgeons / Q000523:psychology*
keywords: Interpersonal and Communication Skills; Medical Knowledge; Practice-Based Learning and Improvement; competency-based education; evidence-based medicine; procedural variation; surgical education; technical decision making; workplace-based assessment