Supporting self-regulated-learning in colonoscopy training-A comparison cohort trial.

Aim: This study aimed to demonstrate that using a self-regulated learning (SRL) approach can improve colonoscopy performance skills. Background: Colonoscopy is the gold standard for detecting colorectal cancer and removing its precursors: polyps. Acquiring proficiency in colonoscopy is challenging, requiring completion of several hundred procedures. SRL seems to be beneficial to help trainees acquire competencies in regulating their future learning processes and enhance the outcomes of current learning situations. SRL is a learner-centred approach that refers to a trainee's ability to understand and control their learning environment, including cognitions, motivations and emotions. The key abilities include self- and situational awareness, task analysis, and strategic planning. This study is the first to use an SRL approach for workplace-based colonoscopy training. Methods: In this comparison cohort trial, participants used two SRL supports: a self-review of videotaped performance, and an online learning platform with procedural and conceptual knowledge about colonoscopy. In the control cohort, participants performed patient-based colonoscopy as usual in their departments. Improvement was monitored via three video-based ratings (study start, end of the study period, and follow-up) using the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT). Outcomes were analysed using two-way analysis of variance with repeated measurements. Results: This study recruited 21 participants (12, intervention cohort; nine, control cohort); 58 videos were recorded. The intraclass correlation coefficient was 0.88 (95% CI 0.61-0.98; p < 0.001). The global rating scale (GRS) and checklist (CL) in GiECAT were analysed separately. No statistically significant main effects of cohort (GRS: F(1,16) = 2.84, p = 0.11; CL: F(1,16) = 1.06, p = 0.32), test (GRS: F(2,32) = 2.56, p = 0.09; CL: F(2,32) = 0.76, p = 0.48), or interactions between cohort and test were observed (GRS: F(2,32) = 1.16, p = 0.33; CL: F(2,32) = 1.01, p = 0.37). Conclusions: SRL in patient-based colonoscopy is feasible; however, no clear effect on performance scores was observed.

Opportunity to Perform - Should Simulation-Based Surgical Training be Provided on Demand or on Supply?

Introduction: The aim of the study was to assess the surgical case volume of residents before and after simulation-based training in hip fracture surgery provided on demand versus knee and shoulder arthroscopy provided on supply. Materials and Methods: A retrospective analysis of surgical case volume in hip fracture surgery and arthroscopic shoulder and knee procedures 90 days before and after simulation-based training of either procedure. Sixty-nine orthopedic residents voluntarily participating in either simulation-based training. Hip fracture surgery simulation was provided on supply, ie, whenever 1-2 residents applied for the course, while the arthroscopic simulation course was supplied twice yearly. Results: Thirty-four residents participated in hip fracture simulation on demand and 35 residents participated in arthroscopic simulation on supply. The surgical case volume of hip fracture osteosynthesis increased from median 2.5 (range: 0-21) to median 11.5 (1-17) from 90 days before to the 90 days after the simulation-based training on demand. The median difference was 6.5 procedures (p < 0.0003). On the contrary, the surgical case volume in shoulder and knee arthroscopy was low both before and after the simulation on supply, ie, median 2 (0-22) before and median 1 (0-31) after. The median difference was 0 (p = 0.21). Conclusions: Simulation on demand was associated with increased opportunities to perform in the clinical environment after the simulation-based training compared with simulation on supply. Simulation-based training should be aligned with the clinical rotation of the residents. Simulation on demand instead of supply on fixed dates may overcome this organizational issue of aligning training with the opportunity to perform.

Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites.

OBJECTIVE: Burnout and mental illness are frequent among healthcare professionals, leading to increased sick leave. Simulation-based team training has been shown to improve job satisfaction and mental health among healthcare professionals. This study seeks to investigate the relationship between simulation-based team training and sick leave. DESIGN: Cohort study. SETTING AND INTERVENTION: Five Danish hospitals. PARTICIPANTS: A total of 15 751 individuals were screened for eligibility. To meet the eligibility criteria, individuals had to be employed in the same group (intervention or control) for the whole study period. A total of 14 872 individuals were eligible for analysis in the study. INTERVENTION: From 2017 to 2019, a simulation-based team training intervention was implemented at two hospital sites. Three hospital sites served as the control group. OUTCOME MEASURES: Data on sick leave from 2015 to 2020 covered five hospital sites. Using a difference-in-difference analysis, the rate of sick leave was compared across hospital sites (intervention vs control) and time periods (before vs after intervention). RESULTS: Significant alterations in sick leave were evident when comparing the intervention and control groups. When comparing groups over time, the increase in sick leave was -0.3% (95% CI -0.6% to -0.0%) lower in the intervention group than in the control group. The difference-in-difference for the complete case analysis showed that this trend remained consistent, with analysis indicating a comparable lower increase in sick leave by -0.7% (95% CI -1.3% to -0.1%) in the intervention group. CONCLUSION: The increase in sick leave rate was statistically significantly lower in the intervention group, implying that simulation-based team training could serve as a protective factor against sick leave. However, when investigating this simulation intervention over 5 years, other potential factors may have influenced sick leave, so caution is required when interpreting the results.

Ward round communication with older patients.

OBJECTIVES: Ward round communication is essential to patient care. While communication in general with older patients is well described, little is known about how communication with older patients and their relatives at ward rounds can be optimised. Hence, this scoping review aims to provide an overview of ward round communication with older patients. Furthermore, the review investigates barriers to the optimal communication. Such an overview would provide a point of departure for developing future health care professionals' education in ward round communication training. METHOD: A scoping review was performed by searching CINAHL, Embase, MEDLINE, and PubMed databases. The search strategy included terms synonymous with "ward rounds" and "older patients." We included studies regarding communication with patients above 65 years during ward rounds. Thematic analysis was applied. RESULTS: Seven of the 2322 identified papers were included in the present review. Thematic analysis revealed three overall themes: Communication strategy, frailty and patient participation, and organisational and age norm challenges. Barriers included frailty-related patient characteristics and imbalance of power between physicians and patients. Papers focused mainly on what the optimal ward round communication should include rather than how it should be performed. CONCLUSION: Characteristics of frail older patients and organisational barriers challenge effective and safe ward round communication. Little is known about how ward round communication with frail older patients and their relatives can be optimised.

Technical, Non-Technical, or Both? A Scoping Review of Skills in Simulation-Based Surgical Training.

OBJECTIVE: Technical and non-technical skills are traditionally investigated separately in simulation-based surgical training (SBST). Recent literature has indicated an interrelation of these skills, but a clear relationship is yet to be established. This scoping review aimed to identify published literature on the use of both technical and non-technical learning objectives in SBST and investigate how the entities are related. Additionally, this scoping study reviewed the literature with the aim of mapping how publications on technical and non-technical skills within SBST have changed over time. DESIGN: We conducted a scoping review using the 5 step framework by Arksey and O'Malley and reported our results according to the PRISMA guidelines for scoping reviews. Four databases, PubMed, Web of Science, Embase and Cochrane Library, were systematically searched for empirical studies on SBST. Studies within surgical training addressing both technical and non-technical learning objectives and presenting primary data were included for further analysis. RESULTS: Our scoping review identified 3144 articles on SBST published between 1981 and 2021. During our analysis, an emphasis on technical skills training in published literature was identified. However, recent years have seen an immense increase of publications within either technical or non-technical skills. A similar trend is seen in publications addressing both technical and non-technical. In total, 106 publications addressed both technical and non-technical learning objectives and were included for further analysis. Only 45 of the included articles addressed the relationship between technical and non-technical skills. These articles mainly focused on the effect of non-technical skills on technical skills. CONCLUSIONS: Though literature on the relationship between technical and non-technical skills remains scarce, the included studies on technical skills and non-technical skills such as mental training suggest such a relationship exists. This implies that the separation of the skill sets is not necessarily beneficial for the outcome of SBST. A shift towards seeing technical and non-technical skills as intertwined may enhance learning outcomes from SBST.

Exploring training needs of newly graduated medical doctors to inform the undergraduate simulation-based curriculum: a national Delphi consensus study.

PURPOSE: Mastering technical procedures is a key component in succeeding as a newly graduated medical doctor and is of critical importance to ensure patient safety. The efficacy of simulation-based education has been demonstrated but medical schools have different requirements for undergraduate curricula. We aimed to identify and prioritize the technical procedures needed by newly graduated medical doctors. METHODS: We conducted a national needs assessment survey using the Delphi technique to gather consensus from key opinion leaders in the field. In the first round, a brainstorm was conducted to identify all potential technical procedures. In the second round, respondents rated the need for simulation-based training of each procedure using the Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula (CAMES-NAF). The third round was a final elimination and prioritization of the procedures. RESULTS: In total, 107 experts from 21 specialties answered the first round: 123 unique technical procedures were suggested. Response rates were 58% and 64% in the second and the third round, respectively. In the third round, 104 procedures were eliminated based on the consensus criterion, and the remaining 19 procedures were included and prioritized. The top five procedures were: (i) insert peripheral intravenous catheter, (ii) put on personal protection equipment, (iii) perform basic airway maneuvers, (iv) perform basic life support, and (v) perform radial artery puncture. CONCLUSION: Based on the Delphi process a final list of 19 technical procedures reached expert consensus to be included in the undergraduate curriculum for simulation-based education.

Ticket to perform: an explorative study of trainees' engagement in and transfer of surgical training.

BACKGROUND: Research suggests that simulation-based surgical skills training translates into improved operating room performance. Previous studies have predominantly focused on training methods and design and subsequent assessable performances and outcomes in the operating room, which only covers some aspects of training engagement and transfer of training. The purpose of this qualitative study was to contribute to the existing body of literature by exploring characteristics of first-year trainees' engagement in and perceptions of transfer of surgical skills training. METHODS: We conducted an explorative study based on individual interviews with first-year trainees in General Surgery, Urology, and Gynaecology and Obstetrics who participated in a laparoscopic skills training program. Informants were interviewed during and two months after the training program. A thematic cross-case analysis was conducted using systematic text condensation. RESULTS: We interviewed 12 informants, which produced 24 transcripts for analysis. We identified four main themes: (1) sportification of training, (2) modes of orientation, (3) transferrable skills, and (4) transfer opportunities. Informants described their surgical training using sports analogies of competition, timing, and step-by-step approaches. Visual orientations, kinaesthetic experiences, and elicited dialogues characterised training processes and engagement. These characteristics were identified in both the simulated and the clinical environment. Experiences of specific skills transfer included ambidexterity, coordination, instrument handling, and visuospatial ability. General transfer experiences were salient in informants' altered training approaches. Informants considered the simulation-based training an entry ticket to perform in the operating room and mentioned supervisor-trainee relationships and opportunities in the workplace as critical conditions of transfer. CONCLUSIONS: Our findings elucidate characteristics of surgical training engagement that can be interpreted as self-regulated learning processes that transcend surgical training environments. Despite appreciating the immediate skills improvements resulting from training, trainees' narratives reflected a struggle to transfer their training to the clinical setting. Tensions existed between perceptions of transferable skills and experiences of transfer within the clinical work environments. These results resonate with research emphasising the importance of the work environment in the transfer process. Our findings provide insights that may inform the development of training programs that support self-regulated learning and transfer of training from the simulated to the clinical environment.

Using simulation-based training during hospital relocation: a controlled intervention study.

BACKGROUND: During hospital relocations, it is important to support healthcare professionals becoming familiar with new settings. Simulation-based training seems promising and in situ simulation has been suggested as a beneficial educational tool to prepare healthcare professionals for relocation. This study aimed to investigate the impact of a simulation-based training intervention on health professionals´ readiness to work in their new environment, as well as investigate sick leave before and after relocation. METHODS: The study was a controlled intervention study implemented at a university hospital in Denmark. Simulation was used to prepare employees for workflows prior to relocation. Before relocation, 1199 healthcare professionals participated in the in situ simulation-based training program. Questionnaires on readiness to perform were distributed to participants at pre-, post-, and follow-up (6 months) measurement. In addition, data on participants' sick leave was gathered from a business intelligence portal. To compare dependent and independent groups, paired and unpaired t tests were performed on mean score of readiness to perform and sick leave. RESULTS: Compared to the control group, healthcare professionals participating in the intervention felt significantly more ready to work in a new hospital environment. As a measure of psychological wellbeing, register data indicated no difference in sick leave, when comparing intervention and control groups before and after participating in the in situ simulation-based training program. CONCLUSIONS: Healthcare professionals felt significantly more ready to work in a new environment, after participating in the in situ simulation-based training program, indicating that the intervention supported healthcare professionals during relocations. This may mitigate feelings of uncertainty; however, further research is needed to explore such effects. TRIAL REGISTRATION: The study was approved by The Regional Ethics Committee (no. 1-16-02-222-22).

Re-examining the integration of routine and adaptive expertise: there is no such thing as routine from a motor control perspective.

The study of adaptive expertise in health professions education has focused almost exclusively on cognitive skills, largely ignoring the processes of adaptation in the performance of precision technical skills. We present a focused review of literature to argue that repetitive practice is much less repetitive than often perceived. Our main thesis is that all skilled movement reflects components of adaptive expertise. Through an overview of perspectives from the field of motor control and learning, we emphasize the interplay between the inherent noisiness of the human motor architecture and the stability of motor skill performances. Ultimately, we challenge the very idea of routine. Our goal is threefold: to reconcile common misconceptions about the rote nature of routine precision skill performance, to offer educators principles to enhance adaptive expertise as an outcome of precision skill training, and to expand the conversation between 'routine' and 'adaptive' forms of expertise in health professions education.

Balancing closure and discovery: adaptive expertise in the workplace.

Residents must develop knowledge, skills, and attitudes to handle a rapidly developing clinical environment. To address this need, adaptive expertise has been suggested as an important framework for health professions education. However, research has yet to explore the relationship between workplace learning and adaptive expertise. This study sought to investigate how clinical supervision might support the development of adaptive expertise. The present study used a focused ethnography in two emergency departments. We observed 75 supervising situations with the 27 residents resulting in 116 pages of field notes. The majority of supervision was provided by senior physicians, but also included other healthcare professionals. We found that supervision could serve two purposes: closure and discovery. Supervision aimed at discovery included practices that reflected instructional approaches said to promote adaptive expertise, such as productive struggle. Supervision aimed at closure-included practices with instructional approaches deemed important for efficient and safe patient care, such as verifying information. Our results suggest that supervision is a shared practice and responsibility. We argue that setting and aligning expectations before engaging in supervision is important. Furthermore, results demonstrated that supervision was a dynamic process, shifting between both orientations, and that supervision aimed at discovery could be an an appropriate mode of supervision, even in the most demanding clinical situations.

Healthcare professionals' experience of using in situ simulation training in preparation for the COVID-19 pandemic: a qualitative focus group study from a Danish hospital.

OBJECTIVES: The COVID-19 pandemic forced hospital organisation and healthcare professionals to prepare for large quantities of patients in isolation rooms. In situ simulation may seem promising in order to manage the organisational changes that the pandemic require. This study aims to investigate in situ simulations influence on healthcare professional's self-perceived preparedness to face the pandemic. DESIGN: A qualitative focus group study. SETTING: We conducted full scale in situ simulations over a 3-week period in April 2020, including 277 healthcare professionals, at a Danish University Hospital. Subsequently, six semistructured focus group interviews, including 22 participants from the simulations, were conducted in May 2020. PARTICIPANTS: 22 healthcare professionals participated in the focus group interviews. METHODS: The simulations consisted of a briefing, two scenarios focusing on acute respiratory insufficiency and correct use of personal protective equipment (PPE), and a debriefing. We conducted six focus group interviews using comparable semistructured interview guides focusing on the organisational restructuring of the departments and outcomes of the needs-driven simulation-based programme. We used thematic analysis to identify main themes. RESULTS: The informants perceived that the simulations resulted in positive experiences for the healthcare professionals and perceived the organisational changes as effective. They highlighted that simulation enhanced teamwork, demystified the COVID-19 disease, and improved skills, in correct use of PPE and acute treatment of COVID-19 patients. Data revealed that a predefined simulation task force including both experienced simulators and medical experts for facilitation of in situ simulation would be beneficial. CONCLUSION: In situ simulation may be useful to enhance learning on organisation and individual level during a pandemic. This educational activity could serve an important role in facilitating hospital preparation and education of large numbers of healthcare professionals during a healthcare crisis. Introduction of a simulation task force is suggested to handle coordination and rapid enrolment across the hospital.

Identifying technical skills and clinical procedures in surgery for a simulation-based curriculum: a national general needs assessment.

BACKGROUND: The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery. METHODS: A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study. RESULTS: Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list. CONCLUSION: Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.

Remote training in laparoscopy: a randomized trial comparing home-based self-regulated training to centralized instructor-regulated training.

BACKGROUND: Simulation-based surgical training (SBST) is key to securing future surgical expertise. Proficiency-based training (PBT) in laparoscopy has shown promising results on skills transfer. However, time constraints and limited possibilities for distributed training constitute barriers to effective PBT. Home-based training may provide a solution to these barriers and may be a feasible alternative to centralized training in times of assembly constraints. METHODS: We randomly assigned first-year trainees in abdominal surgery, gynecology, and urology to either centralized instructor-regulated training (CIRT) or home-based self-regulated training (HSRT) in laparoscopy. All participants trained on portable box trainers providing feedback on metrics and possibility for video reviewing. Training in both groups was structured as PBT with graded proficiency exercises adopted from the Fundamentals of Laparoscopic Surgery (FLS). The HSRT group trained at home guided by online learning materials, while the CIRT group attended two training sessions in the simulation center with feedback from experienced instructors. Performance tests consisted of hand-eye and bimanual coordination, suture and knot-tying, and FLS exercises. We analyzed passing rates, training time and distribution, and test performances. RESULTS: Passing rates were 87% and 96% in the CIRT and HSRT group, respectively. HSRT facilitated distributed training and resulted in greater variation in training times. Task times for hand-eye and bimanual coordination were significantly reduced between pretest and posttest in both groups. Trainees maintained their posttest performances at the 6-month retention test. Our analyses revealed no significant inter-group differences in performances at pretest, posttest, or retention test. Performance improvements in the two groups followed similar patterns. CONCLUSION: CIRT and HSRT in laparoscopy result in comparable performance improvements. HSRT in laparoscopy is a feasible and effective alternative to CIRT when offered inside a supportive instructional design. Further research is needed to clarify trainees' preferences and explore facilitators and barriers to HSRT.

Preparing an orthopedic department for COVID-19.

Background and purpose - The COVID-19 pandemic has disrupted healthcare services around the world. We (1) describe the organizational changes at a level 1 trauma center, (2) investigate how orthopedic healthcare professionals perceived the immense amount of information and educational activities, and (3) make recommendations on how an organization can prepare for disruptive situations such as the COVID-19 pandemic in the future. Methods - We conducted a retrospective survey on the organizational restructuring of the orthopedic department and the learning outcomes of a needs-driven educational program. The educational activities were evaluated by a non-validated, 7-item questionnaire. Results - The hospital established 5 COVID-19 clusters, which were planned to be activated in sequential order. The orthopedic ward comprised cluster 4, where orthopedic nursing staff were teamed up with internal medicine physicians, while the orthopedic team were redistributed to manage minor and major injuries in the emergency department (ED). The mean learning outcome of the educational activities was high-very high, i.e., 5.4 (SD 0.7; 7-point Likert scale). Consequently, the staff felt more confident to protect themselves and to treat COVID-19 patients. Interpretation - Using core clinical competencies of the staff, i.e., redistribution of the orthopedic team to the ED, while ED physicians could use their competencies treating COVID-19 patients, may be applicable in other centers. In-situ simulation is an efficient tool to enhance non-technical and technical skills and to facilitate organizational learning in regard to complying with unforeseen changes.

Identifying and prioritising technical procedures for simulation-based curriculum in paediatrics: a Delphi-based general needs assessment.

OBJECTIVES: To identify and prioritise technical procedures that should be integrated in a curriculum of simulation-based procedural training in paediatrics using the Delphi method. STUDY DESIGN: National general needs assessment using a Delphi process was completed among 93 key opinion leaders in paediatrics in Denmark. Delphi round 1 identified technical procedures. Round 2 explored frequency of procedures, number of paediatricians performing the procedures, risks and/or discomfort for patients and feasibility for simulation-based training. Round 3 included final elimination and reprioritisation. RESULTS: Response rates in the Delphi rounds were 73%, 71% and 72%. We identified 37 procedures in Delphi round 1, preprioritised in round 2, resulting in a final list of 19 procedures in round 3. Strong correlation between the prioritisation from the second and third Delphi rounds was identified, Spearman's r of 0.94 (p<0.0001). Top five on the final list were acute neonatal airway management, acute non-neonatal airway management, non-neonatal peripheral intravenous and intraosseous access, neonatal vascular access and advanced heart lung resuscitation. CONCLUSION: We identified and prioritised 19 technical procedures in paediatrics that are suitable for simulation and may be used as a guide for the development of simulation-based curriculum in paediatrics.

HipSim - hip fracture surgery simulation utilizing the Learning Curve-Cumulative Summation test (LC-CUSUM).

Background and purpose - Virtual reality simulation of hip fracture surgery is available for orthopedic residents nationwide in Denmark. Summative assessment of learning applying the learning curve cumulative summation test (LC-CUSUM) has not been utilized in orthopedic simulation training. The strength of the LC-CUSUM is that it assumes incompetency and signals competency based on solid statistics. We investigated the LC-CUSUM characteristics of novices stepwise mastering the simulated dynamic hip screw (DHS) procedure. Material and methods - 32 1st-year orthopedic residents participated in HipSim and its 3 subsequent LC-CUSUM evaluations: placing a Kirschner wire, placing a Kirschner wire in different patients, and performing the entire DHS procedure in different patients. The career status of the participants, i.e., still working in orthopedics or in another specialty was recorded ≥ 2 years after participation and associated with the simulation performance (passed/failed). Results - 13/14 participants passing HipSim according to LC-CUSUM were still working in orthopedics, while 9/18 participants failing HipSim had quit orthopedics at ≥ 2 years follow-up. The simulator-generated feedback did not statistically significantly differ between the groups. Interpretation - LC-CUSUM and its summative pass/fail assessment of each simulation was feasible in this formative simulation program. Clinical educators can be reassured that participants passing HipSim are likely to continue to 2nd-5th year of residency, while failing HipSim should raise concerns and trigger career counselling and clinical supervision. The motivational aspect of LC-CUSUM pass/fail assessment when designing formative simulation training warrants further research.

Being a surgeon or doing surgery? A qualitative study of learning in the operating room.

CONTEXT: A key concern for surgical educators is to prepare students to perform in the operating room while ensuring patient safety. Recent years have seen a renewed discussion of medical education through practice theoretical and sociomaterial lenses. These lenses are introduced to understand and prepare the learner to perform in the given context. This paper takes its point of departure from practice theory by introducing a lens through which to understand learning environments in surgery. METHODS: Using a multi-site ethnographic and practice-based design, this study investigates how aspiring surgical students are stirred into surgical practices and learn to engage as surgeons. During 70 hours of observations of medical students' participation in the operating room, we analysed how the phenomenon of surgical learning can be perceived as instances of transformation in and among social practices. RESULTS: By applying an analytical perspective, this article highlights the use of practice theory in surgical education, which can help to establish a firmer understanding of the learning environment and thereby help educators to improve curricula and prepare students more effectively to enter surgical training. CONCLUSIONS: The use of a practice theory adds the perspective that the education of surgeons needs to take the sayings, doings and relatings that constitute a surgical practice into account when preparing students to perform in their future workplace. In this way, surgical training can be perceived as a process of being stirred into practice. This means that one learns by participating in the practice of providing high-quality care, where the aim is to teach students to be surgeons instead of teaching them to perform surgery.