Success for the academic surgical training programs of the future requires an intentional pursuit of cognitive diversity for both learners and teachers, the use of creative educational and assessment methods, and the support of effective educational teams to promote continuous learning at all levels. When surgical training programs embrace these values rather than relying on the assumed by-products of a busy clinical program or faculty expertise, the benefits to the program culture extend far beyond the learners themselves. For teaching to become a cultural priority for busy residents during training, there must be legitimate and visible role modeling of such behavior from faculty. Without positive role modeling, expectations and encouragement will not be enough. It is also important for residents to observe faculty advancing in their careers in recognition of educational contributions in order to engender trust in the larger system and the extra effort that improvement requires. With these influences, residents will be more likely to pay forward the sorts of behaviors that benefitted them in their own development.

Medical students—especially those pursuing surgical careers—derive great benefit from excellent resident teaching. Peer residents benefit from each other’s elevated expectations of deliberate learning and dynamic refinement of knowledge. The program improves as excellent applicants are drawn to a supportive learning environment and the opportunity to develop themselves as educators. In a learning culture centered on residents and students, faculty surgeons benefit from healthy challenges to their viewpoints or traditions and the inspiration to continue to develop themselves as lifelong learners. As a complex organization begins to view itself as a system that needs to continuously “learn” from the outcomes of its processes in order to improve them, it is easy to understand how the profession of surgery and future surgical patients benefit from a healthcare system led by facile learners and dedicated educators at all levels.

From the perspective of program and department leadership, creating a culture that prioritizes resident teaching can pay notable dividends. It is worthwhile to understand the motivators to do so. There are external expectations for residents to develop these skills delineated in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements. As an aspect of their interpersonal and communication skills, the resident must demonstrate competence in educating patients, families, students, residents, and other healthcare professionals.¹ In the first version of the milestones, teaching was considered an important developmental domain of Practice-Based Learning and Improvement. In the second version of the milestones, because of the focus on development of a surgeon to serve their patient in a complex healthcare system, teaching skills are not evaluated distinctly but instead integrated into many of highest level anchors of competencies such as Practice-Based Learning and Improvement and Interpersonal and Communication Skills in terms of coaching, role modeling, and enhancing team performance.² The Liaison Committee on Medical Education clearly delineates in its standards for medical student education that residents who supervise medical students must be prepared for their roles in teaching and assessment and that the medical school must provide resources to enhance residents’ skills in these regards.³

Even if not driven by external requirements, most academic training programs that have the goal of creating academic surgical faculty would choose to develop and evaluate resident teaching of medical students. This is often encouraged by integrating residents into the medical student evaluations of their educators (traditionally the faculty). Formative and summative feedback about teaching evaluations can occur as part of the end-of-rotation evaluations or during the semiannual reviews with the program director.

However, the most effective and desirable motivators should be internal to the program and be totally apparent in the values and daily decisions of the leadership. This can be best illustrated when considering the converse when teaching is not a top-tier priority (which can easily become the default condition without deliberate attention). In most current medical school curricula, students typically have less exposure to Surgery than in years past as a function of the exponential expansion of specialty scientific knowledge and the unique needs of training physicians for the needs and complexities of contemporary medical practice. Even during clerkship rotations, students are often required to be in formal educational sessions such as lectures, seminars, etc. instead of the practical learning environment of the operating room or surgical clinic. Add to that the increasing time and productivity demands on faculty, and it is easy to understand how teaching of medical students can be marginalized unless it is expected, encouraged, and recognized. As residents are among the most influential medical student teachers in the current environment, efforts to support their success can have a major ripple effect. Therefore, the motivation for residents to teach effectively can become a feature of program culture that becomes propagated by each new class of outstanding resident teachers. From a recruitment perspective, it can be very effective to consider teaching experience and skill as a critical attribute to be sought and evaluated during the resident selection process. At least one interviewer should explore the applicants’ self-assessment of their skills and attitudes in this domain if the cultural expectations are to be sustained. The program must be built around the right sort of attitudes and talents to foster this within the culture, and recruiting residents for whom this is not a priority can impede group progress in an insidious way—particularly in terms of the supportive learning environment. Group accountability can be fostered by peer evaluation of teaching in the workplace—particularly during patient rounds and in the operating room.

As the traditional lines between a teacher and learner have blurred significantly, it is important to acknowledge evolving characteristics and expectations of different team members to design for educational success and sustainability. Each new generation of surgeons shares a common history and frame of reference that is unique from those that came before, and the concepts of generational segmentation can be useful in adapting to the needs of current learners⁴ (Figure 17.1). The majority of current surgical trainees and medical students are members of Generation Y. Also referred to as Millennials, most were born between 1985 and 2005. In general terms, Millennials have been deeply influenced by the rise of the Internet, smartphone technology, reality television, social media, school shootings, the great recession, 9/11, and global terrorism. Collectively, Millennials have been described as self-confident, civic-minded, achievement-oriented, and
technologically savvy but also as self-centered and entitled. An important characteristic is that Millennials crave feedback and may feel somewhat uncomfortable without it.

Practicing surgeons are most likely to be Baby Boomers (born approximately 1945-1964) or members of Generation X (born approximately 1965-1984). Just like Generation Y, these generations were influenced by a common history. They also share common characteristics, some of which can clash with Millennial values. While this divergence is not unique to the field of surgery, it is particularly relevant because of the high-stakes nature of surgical education and the intimacy of the interaction between surgeons and trainees. For relationships between surgeons and trainees to be optimized, both parties must recognize the inherent conflicts between generations and work to create interactions that highlight the positive attributes of each group. To add this layer of understanding to interactions requires both learners and teachers to realize these attributes may be as much cultural phenomena as they are individual. Embracing and understanding these differences can elevate the performance of the entire educational team. Accomplishing this can be a very practical expression of the current goals of cognitive diversity and inclusion within a traditionally hierarchical structure. When all parties can realize that students, residents, and faculty are fundamentally similar in goals and values but simply exist on different phases of the developmental and experiential spectrum, it can be potentially liberating to the inherited culture and can foster innovation and open communication. To do so effectively requires flattening the hierarchy or at least making the communication within it more fluid.

The following generalized observations may be helpful in designing surgical education for Millennial trainees—primarily surgical residents and medical students: