Given the many competing demands placed on academic surgeons—research productivity, revenue generation, institutional service, and career advancement—it can be easy to overlook the fact that the task of preparing future generations of surgeons for independent practice has always been the core mission of academic surgery. Transferring clinical skills and wisdom to trainees is not only the academic surgeon’s defining role but her only role that could never be fulfilled by anyone else. Despite the self-professed primacy of the training mission in many academic departments of surgery, the task of clinical teaching is often the first to be taken for granted. As it brings no professional titles or accolades to most and is usually not directly compensated financially, teaching can quickly transform from priority to burden in the mind of the academic surgeon.

The goal of this chapter is to motivate the reader to reevaluate the place clinical education has in the landscape of her many professional duties and to ask whether it may be time to rethink this. In the first segment, we will recall the experience of clinical education from the perspective of the learner. In the second, we will see how this perspective can inform the teacher’s efforts to be more effective. In the final segment, we will explore how a reorientation to the professional imperative of clinical education could bring meaning and fulfillment to the academic surgeon.

The system of graded responsibility means that each passing training year feels like a graduation. The experience of learning to manage the physiology of postoperative patients and distinguishing “sick” from “not sick” gives the finishing intern the confidence to manage critically ill patients in the intensive care unit in her second year. Viewed from the intern’s base camp, the summit seems nearly impossible to reach—the program is long, with seemingly infinite nuances to master. Junior residents, faced with such a stark contrast between their own skills and wisdom and those of their chief residents, may feel that they might never competently lead the team, much less get to the level of the attending surgeon. (Only later does one realize that “mastery” is an illusory concept, and “finishing” really means “just getting started.”)

This chasm in experiential wisdom between trainees and faculty is why residents tend to bestow respect so quickly onto their faculty surgeons and mentors; who does not recall the chairperson of surgery at the time of our residency with a sort of hero worship? Who among us could not replay from memory exact conversations we had with faculty mentors at pivotal moments of our training? Trainees view their faculty not simply as sources of wisdom but as templates by which they hope to construct their professional lives. It is a very common experience for residents to envision their future selves as an amalgamation of specific faculty mentors, noting in real time how they will someday emulate their admirable characteristics. We recall specific examples from our own training: the equanimity of one faculty during intraoperative misadventures, the humility and honesty of another when discussing his complications in conferences, the discretion of a technically gifted surgeon who frequently assisted his colleagues but never spoke of it, and the folded hands and compassionate demeanor of one when delivering difficult news to patients. (We also recall examples that we vowed not to emulate.) Viewed in this light, it is neither surprising nor insignificant that small gestures of interest and advocacy on the part of faculty surgeons to trainees are usually received with a disproportionate and unexpected appreciation and gratitude.

Despite how interminable it sometimes seems, the residency eventually comes to an end. When that happens, the transition from training to independence is a landmark milestone best navigated by those who possess an optimized balance of confidence and insecurity. Trainees may begin their internship with a sense that the residency process is the totality of surgical education; by the conclusion of their formal training, the healthy surgeon recognizes that she is still ascending the learning curve at a steep angle. Their ability to do this once outside the protective structure of a residency is enabled in part by a sense of confidence built from their own cumulative clinical experiences as well from the collective wisdom of their mentors. However, the safe young surgeon is also aware of her limits and blind spots, and this healthy sense of insecurity hopefully motivates her to seek out education and help when needed. Although confidence may grow and insecurity fade as experience builds and judgment matures, some degree of both is necessary to sustain a safe and effective surgeon over an entire career.

In addition to acquiring cognitive knowledge and technical skills, the trainee also spends her surgical residency developing habits that will guide the rest of her professional career. Many of these habits are inculcated with great intention and effort; for example, the ethic of personally reviewing films and not simply reading radiologists’ reports can become internalized after repetitive admonition and verification. Other habits are cultivated naturally, evolving through personal experience; for example, it is possible for a resident to receive excellent intensive care training with a durable antipathy for critical illness that leads her to avoid risky operations in the future.

Beyond the important dynamics of competence and safety, the surgical career is also marked by the need to continually locate and relocate meaning and fulfillment, both within and outside the hospital. We are all becoming increasingly aware of the insidious danger of burnout, which is very real during training.^1,2,3 The risk of burnout is like the risk of surgical complications; both are ever-present pitfalls that will accompany the surgeon throughout her career. As with surgical complications, the best hope is to avoid burnout, and the best way to avoid burnout is to implement best practices to mitigate its likelihood of occurrence. As with surgical complications, occasional encounters with burnout may be unavoidable, and the best way to handle these moments is to own strategies to understand and reverse their causes.

The healthy surgeon begins to construct these practices and strategies during residency with the same intentionality as that applied to building clinical skills. Until recently, this was a self-directed and accidental learning process, with each trainee taking on the task of (hopefully) discovering them on her own. Training programs are beginning to incorporate practices and strategies against burnout into their curricula. As is often the case in scientific studies of human experience, investigative attention to the problem of burnout is rediscovering timeless lessons. The seed of burnout often grows when the source of one’s personal meaning and fulfillment becomes overwhelmed by more mundane and practical obligations. To prevent burnout, it is undoubtedly important to restrict those mundane and practical obligations; however, the practical, economic, and administrative realities of medicine, especially as a trainee, tend to tip the balance in the wrong direction. Busy schedules, financial and legal duties, and documentation inefficiencies in the life of a surgeon are unlikely to go away. Viewed in this light, an equally important strategy against burnout is to remember and fixate upon those things that offer personal significance and genuine reward: service and contribution to a greater good and the opportunity to teach those who come after us, to name but two. Unfortunately, the opportunity to lose sight of this begins in residency; fortunately, the opportunity to learn ways to retain one’s focus on this can also begin in residency.

The best first-grade teachers remember and understand what it was like to be a first-grader. The same is true for those of us who teach residents in their third and fourth decades of life. Consider the task of showing someone how to insert a laparoscopic port. When teaching this to a practicing surgeon wishing to learn laparoscopic liver surgery, this is a quick task of communicating port site locations for optimal operative ergonomics. When teaching this to a medical student, this is a laborious and multistep discussion in which none of the smallest details (the shape and design of the port, how to position your hands on the port, safe and unsafe places to insert a port) can be overlooked. There are many differences between these two scenarios, but the most informative difference is in the need the learners bring to the learning experience. For the practicing surgeon, the need is to acquire an entirely new operative skill set; if she comes away with a safe and effective roadmap of port site locations, the learning experience will have been a success. For the medical student, the need is to discover if the operating room is a place where she might eventually find career satisfaction; if she comes away engaged and interested (or not) by the thought process and physical task of port insertion, the learning experience will have been a success. To extend this
illustration, if the teacher were to switch the motivations of the two learners in her teaching approach to them, the practicing surgeon would walk away from the experience offended and hurt, and the medical student would walk away from the experience confused and alienated.

As discussed in the previous section, the experience of residency is marked by an emotional and cognitive hyperacuity that accentuates one’s receptivity to learning; the potential for outsized influence on the part of faculty mentors, a need to cultivate a healthy balance of confidence and insecurity, and the opportunity to build personal habits that may protect against the creeping influence of burnout (Figure 20.1). How can the academic surgeon use the nature of this experience to be an effective teacher?