• Tavis Apramian, Sayra Cristancho, Chris Watling, Michael Ott, and Lorelei Lingard.
• Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, London, Ontario, Canada. Electronic address: tavis.apramian@schulich.uwo.ca.
• J Surg Educ. 2016 Mar 1; 73 (2): 339-47.

ObjectiveClinical 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 SettingThis 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.ParticipantsOur sample included 99 hours of observation across 45 cases with 14 surgeons. Semistructured, audio-recorded interviews (n = 14) occurred immediately following observational periods.ResultsSurgeons 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.ConclusionsAcknowledging 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.Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

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