The American Journal of Surgery (2015) 209, 107-114

Association for Surgical Education

Student-led learning: a new teaching paradigm

for surgical skills
Jen Hoogenes, M.S., Ph.D.(c)a, Polina Mironova, B.A.b,c,
Oleg Safir, M.D.b,c, Sydney A. McQueen, B.Sc.(Hons), M.Sc.(c)a,
Hesham Abdelbary, M.D.b,c,d, Michael Drexler, M.D.c,e,
Markku Nousiainen, M.Ed., M.D.b, Peter Ferguson, M.D.b,c,
William Kraemer, M.D.b, Benjamin Alman, M.D.b,
Richard K. Reznick, M.Ed., M.D.d,f, Ranil R. Sonnadara, Ph.D.a,b,c,*

a
Department of Surgery, McMaster University, A. N. Bourns Science Building Room 131, 1280 Main
Street West, Hamilton, Ontario, Canada L8S 4K1; bDepartment of Surgery, University of Toronto,
Toronto, Ontario, Canada; cDepartment of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada;
d
Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; eDepartment of Surgery, Tel
Aviv Sourasky Medical Center, Tel Aviv, Israel; fDepartment of Surgery, Queens University, Kingston,
Ontario, Canada

KEYWORDS: Abstract
Residents; BACKGROUND: Competency-based education and simulation are being used more frequently in surgi-
Surgical education; cal skills curricula. We explored a novel student-led learning paradigm, which allows trainees to become
Competency-based more active participants in the learning process while maintaining expert guidance and supervision.
education; METHODS: Twelve first-year orthopedic residents were randomized to either a student-led (SL) or a
Non-technical skills; traditional instructor-led group during an intensive, month-long, laboratory-based technical skills
Residency; training course. A rigorous qualitative-description approach was used for analysis.
Surgical simulation RESULTS: Four prominent themes emerged: instructional style, feedback, peer and instructor collab-
oration, and self-efficacy. Compared with the instructor-led group, there was more peer assistance,
feedback, collaboration, and hands-on and active learning observed in the SL group.
CONCLUSIONS: The flexible and socially rich nature of the SL learning environment may aid in
development of both technical and nontechnical skills early in residency and ultimately privilege later
clinical learning.
2015 Elsevier Inc. All rights reserved.

Recent challenges have led surgical educators to ques-
tion the ability of traditional, apprenticeship-based training
methods to adequately prepare surgical trainees for
* Corresponding author. Tel.: 11-905-525-9140x27209; fax: 11-866-
248-2972.
E-mail address: ranil@skillslab.ca
Manuscript received May 21, 2014; revised manuscript August 11, 2014
independent practice.1 Restrictions on residents work
hours have resulted in fewer opportunities for teaching
and learning in the clinical setting.2 This is especially
true given the ever increasing number and complexity of
surgical procedures that residents must learn. Recent
studies have revealed that surgical residents may not be get-
ting sufficient exposure to essential procedures before
completing their training.3

0002-9610/$ - see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2014.08.037
108
Surgical educators are seeking new approaches to
training residents. Two prominent trends are emerging.
The first is a transition toward competency-based education
(CBE), which aims to prepare physicians to graduate with
demonstrated competencies and de-emphasize time-based
training while assuring greater accountability, flexibility,
and learner centeredness.4 A number of competency frame-
works have been developed, with each built on the notion
that trainees must demonstrate proficiency on key prede-
fined outcomes before being authorized to continue to the
next stage of their training, eventually leading to certifica-
tion for independent practice.58
The second trend is an increasing use of simulation-based
teaching sessions to supplement and enhance traditional
clinical learning. Recent years have seen an exponential
increase in the number of high- and low-fidelity simulators
and bench models, which can be used to teach and perfect
medical and surgical techniques in a low-risk, stress-free
environment before they are applied to the high-stakes
clinical setting.9,10 One important variable that has been
examined with regard to simulation training is the role of in-
dependent learning paradigms, such as student self-guided
learning, which are becoming increasingly popular in resi-
dency programs, especially because of the augmented ease
of access to simulation laboratories.11 Although some studies
have reported that self-guided or self-regulated learning can
provide effective learning environments for trainees, re-
searchers warn that some level of supervision should be
maintained and that complete learner autonomy should not
necessarily be the ultimate goal of medical and surgical edu-
cation.12 The amount of time and influence a teaching clini-
cian provides to learners still needs to be determined.
Additionally, these studies have exclusively examined the
acquisition of technical skills; yet, little is known about
how self-guided learning may affect the acquisition and use
of nontechnical skills.
Our team from the University of Toronto recently
developed a novel training paradigm entitled student-led
learning (SLL). SLL is a new term, coined to set this
approach apart from many buzzwords that permeate
through the literature, such as self-guided, self-regulated,
and student-driven models of learning, many of which have
been interpreted differently by various groups.11,13
Although the primary tenets of SLL are not new, this
approach is a carefully selected combination of key aspects
of a variety of teaching strategies, systematically imple-
mented into a cohesive program. SLL stresses the impor-
tance of trainees autonomous control over the learning
process13,14; yet, unlike self-directed and self-regulated
learning, which are generally unsupervised,11 central to
the SLL paradigm is that an educator is always present to
provide assistance as required and to guide students
through the learning process. Appropriate guidance by con-
tent experts is critical, especially in the earliest, formative
stages of skill acquisition.15 SLL emphasizes the role of
the educator as a facilitator who promotes deliberate,
student-led exploration and practice, providing guidance
The American Journal of Surgery, Vol 209, No 1, January 2015
and an educational framework when necessary.14 Further-
more, trainees who learn under an SLL paradigm are
encouraged to work together in small groups, which con-
trasts with the independent nature of the instructor-
directed, self-guided learner.11
Our initial exploration of the SLL paradigm examined
its ability to enhance the acquisition of technical surgical
skills.16 Learning technical skills is an iterative process,
during which trainees must analyze the skill, break it
down into its components, define goals, and then create
strategies to reach these goals.15 Creating an internal repre-
sentation of what optimal performance should be for each
component allows trainees to compare their actual perfor-
mance against this representation and continue to solicit
additional feedback with each attempt at the skill to
improve their performance.15,17 SLL offers trainees an
environment in which they are free to explore and develop
their own internal representations for skill acquisition
rather than working from templates that are provided
through lectures and demonstrations.16 The SLL approach
also encourages trainees to practice at their own pace and
repeat skills as they deem necessary. Skills are reinforced
through cooperative learning, whereas trainees become
the primary support for their peers, with the instructor
available for assistance as required.
We have previously shown that an SLL paradigm is an
extremely effective approach for enhancing the acquisition
of technical surgical skills.16 In our previous study, SLL
was examined in the context of an intensive, technical sur-
gical skills training course at the University of Toronto,
known as the Toronto Orthopaedic Boot Camp
(TOBC).16,18,19 First-year orthopedic residents who were
taught under the SLL paradigm performed significantly bet-
ter on a series of targeted skills examinations than their
peers who were taught using traditional, instructor-led
methods.16 Although the implementation of SLL has clear
benefits for technical skills acquisition, there is more to be-
ing a competent surgeon than simply being an excellent
technician. Training programs must also develop methods
for teaching nontechnical skills, such as communication,
collaboration, teamwork, and leadership skills.20 Nontech-
nical skills are difficult to quantify, and there is growing
concern that a focus on the achievement of measurable
technical competencies may be overshadowing a variety
of other nontechnical skills, which are essential to the suc-
cess of the profession.20,21
Based on the SLL paradigm design and its success in
technical skill acquisition, we believe it may be more useful
than a traditional, instructor-led framework for developing
surgical trainees nontechnical skills. Current laboratory-
based surgical training courses may be overemphasizing
technical skills and overlooking the importance of devel-
opment of nontechnical skills.21 A primary aim of the SLL
approach is to allow trainees to take more control over the
learning process, perhaps promoting a more cooperative,
social, and active learning environment, which may
improve problem-solving and leadership abilities.22,23
J. Hoogenes et al. Student-led learning
Working together toward a shared learning goal, trainees
are able to challenge one another to achieve a higher level
of thinking, therefore building up stronger mental models.24
Peer learning also improves trainees engagement, partici-
pation, motivation, communication, and attitude.23 Because
of the success of our previous work with the SLL paradigm
and its definitively positive effect on surgical skill acquisi-
tion, we set out to perform a qualitative exploration of
nontechnical skill acquisition between 2 groups of first-
year orthopedic residents: those who were allocated to the
traditional instructor-led (IL) apprenticeship model
compared with those in the student-led (SL) group.
Methods
Design
Research ethics board approval was received, and writ-
ten informed consent was obtained from all participants.
An observational, qualitative-description approach25 was
used to explore how residents learned under the SL and
IL teaching approaches during the TOBC, an intensive,
month-long, laboratory-based technical surgical skills
training program at the University of Toronto.26 Learners
were trained in basic technical surgical skills and those spe-
cific to orthopedic surgery, with skills becoming more com-
plex as the program progressed. Residents were also taught
practical learning strategies designed to serve them
throughout their residency. All residents participated in
both anatomy laboratory and surgical skills center practical
learning sessions. The anatomy laboratory sessions incor-
porated both didactic teaching and demonstration of tech-
niques (using human cadavers), with a specific focus on
identification of anatomic structures and surgical proce-
dural techniques. The surgical skills center sessions were
devoted to extensive practice of the technical skills taught
during the anatomy laboratory sessions using state-of-the-
art simulated bench models and surgical equipment. Resi-
dents completed 8 anatomy laboratory and 9 surgical skills
center sessions (each lasting 3 hours), with 2 additional re-
view sessions as the program neared completion. Both
groups had equal practice time in both the anatomy labora-
tory and surgical skills center. Each group underwent daily
identical didactic sessions before starting the anatomy lab-
oratory and surgical skills center activities. All residents
received the same written objectives and preparation mate-
rial for each session, regardless of the assigned learning
paradigm.
Setting and participants
Participants were randomly allocated to either the SL or
IL group. Participants received a unique identification code
for use throughout the study. SL-group residents were
taught basic surgical skills using a format that focused on
deliberate practice of the skills under facilitator supervision
109
as necessary, allowing for extensive student collaboration
and problem solving, while being given a considerable
amount of autonomy. Residents in the IL group were taught
the same surgical skills; however, the apprenticeship model
that was used included extensive lecture and instruction
periods, followed by thorough demonstrations of each
surgical task.
The teaching faculty consisted of 2 orthopedic surgical
fellows and 7 senior orthopedic residents, who were all
supervised by a staff surgeon. The role of the supervising
staff surgeon was to oversee the program as a whole, and
the supervising staff surgeon did not participate in the
teaching of either group. The fellows served as the primary
instructors (1 per group), whereas the senior residents
assisted with teaching as required. Each of the fellows and
senior residents was assigned to 1 of the 2 groups without
any crossover. The fellows and senior resident educators
were trained by an expert surgical educator on the group-
specific methods and constructs to incorporate during the
sessions. To reduce bias, the SL educators were trained
separately from the IL educators. The formal 3-day training
course provided group-specific teaching advice, strategies,
and suggestions for handling potential scenarios between
instructors, educators, and/or residents. This training
focused on the major tenets of CBE, with a specific
emphasis on SLL principles for the SL educators, partic-
ularly with regard to facilitation rather than traditional
instruction. Teaching techniques for the IL group were
concentrated on constructs of the traditional apprenticeship
model.
Data collection
Three uniformly trained research assistants observed
each group during all didactic, training, and practice
sessions in the anatomy laboratory and surgical skills
center sessions. Extensive field notes were taken to record
residents, educators, and instructors verbal and physical
exchanges. On completion of the TOBC, 1 research assis-
tant conducted semistructured exit interviews with each
resident and the 2 instuctors.27 This process allowed for the
collection of rich qualitative experiential data. Interviews
were audio-recorded and transcribed verbatim. An audit
trail was maintained, and data were triangulated across
investigators.
Data analysis
The field notes and responses of the interviews were
separately analyzed for common themes by 3 independent
researchers who had no previous interaction with the
participants, senior residents, or instructors. All transcripts
were individually analyzed to identify and define themes
and concepts that were unique to the experiences of the
participants. The investigators collaborated iteratively and
developed a thematic codebook, with data reduction
110 The American Journal of Surgery, Vol 209, No 1, January 2015

conducted during each iteration until the codebook was
finalized. Open, axial, and selective coding generated
defined themes that were characteristic of the experiences
of the participants in each group. Separate codebooks were
developed for each group to allow for comparison of
experiences. Recurrent themes from the exit interviews
were also extracted to describe residents and instructors
overall experiences and perceptions of the program.
Results
Nine male and 3 female residents with a mean age of
24.7 years participated. Qualitative content analysis of the
field notes for the anatomy laboratory and surgical skills
center sessions revealed similar themes between the SL and
IL groups; however, the concepts related to each theme
varied considerably between groups. Four primary themes
emerged from the field notes and exit interview data:
instructional style, feedback, peer and instructor collabora-
tion, and self-efficacy. Themes involved a mixture of
intrinsic and extrinsic factors that influenced the learning
experiences of residents throughout the TOBC program
(Table 1).
Instructional style
The IL instructor combined the lectures with multiple
lengthy demonstrations, whereas the participants watched
but were not able to participate until the allotted practice
time. The sessions were principally didactic in nature, and a
running quiz format was used throughout each of the
anatomy laboratory and surgical skills center sessions.
Questions were most often targeted to the group as a whole
and not just to one resident. The instructor then typically
went on to lecture about the answers to the questions.
During practice sessions, the instructor and educators
frequently took over from the residents to demonstrate
correct techniques. Strict verbal directing was used to guide
residents through the task, which was often done more than
once until completed correctly. With time, residents began
to ask more questions of the instructor and educators. This
would usually result in a lecture and demonstration. During

Table 1 Comparison of themes by group

Theme Instructor-led group
Instructional style  Frequent, lengthy lectures
 Frequent takeovers
 Lengthy task demonstrations
 Primarily didactic in nature
 Running quiz format
 Verbal directing
 No explicit encouragement of peer collaboration
Feedback  Infrequent in AL and SSC
 Not spontaneously provided
 Positive feedback sometimes provided when resi-
dents correctly answered questions
 Very limited peer feedback
 Residents most often required solicitation of feed-
back from instructors
Peer and instructor  Rapport was established late in the TOBC
collaboration  Majority of residents chose to work independently,
as instructors did not explicitly encourage group
work, limiting collaboration
 Toward the end of TOBC, residents began to collab-
orate, but not consistently
 Instructors became more hands-off as TOBC
progressed
Self-efficacy  Residents observed more than practiced, diminish-
ing confidence in their competency with certain
tasks due to instructor takeovers
 Lack of time to practice decreased a sense of resi-
dent autonomy
Student-led group
 Infrequent, short lectures
 No takeovers
 Short task demonstrations
 Deliberate practice at own pace
 No quiz format
 Residents were walked through tasks with
questioning and answering to ensure
understanding
 Peer collaboration encouraged
 Frequent in AL and SSC
 Spontaneously provided
 Positive/constructive feedback during demon-
strations and practice
 Peer-to-peer feedback was a common occur-
rence, solicited primarily from peers and less
from instructors as TOBC progressed
 Rapport was established by residents and
instructor from beginning of TOBC
 Residents worked in small and large groups as
encouraged by instructor, allowing for peer
assistance
 Advice was solicited from instructors as last
resort if peers needed assistance
 Dedicated time was set aside for question and
answer periods
 As the TOBC progressed, residents began to as-
sume a teaching role to other peers
 Hands-off approach boosted resident confi-
dence and an increased sense of autonomy
 Residents were allowed to practice until they
explicitly asked for assistance
J. Hoogenes et al. Student-led learning
demonstrations, the instructor often related the simulated
procedure to typical scenarios one might encounter in the
operating room while sometimes describing challenging
cases personally experienced during practice. Residents in
the IL group mostly worked independently and were not
distinctly encouraged by the instructor to work in groups,
although they were not explicitly told not to do so.
The SL instructor used a less-structured, hands-off
observational approach to teaching, allowing residents to
deliberately practice tasks in both the anatomy laboratory
and surgical skills center at their own pace, collaboratively
(or independently if the resident chose to do so). The
didactic sessions were significantly shorter than those in the
IL group, and lecturing was not common following
questions from residents; rather, the questions were often
addressed in groups. If the answer(s) warranted a demon-
stration, the instructor or resident educator would either
demonstrate the technique first and then a resident would
attempt the task, or they would walk the resident through
the technique, offering corrective feedback when necessary.
The instructor and educators were available to answer
questions and offer assistance when asked by residents. A
quiz format was never used, and the instructor did not take
over from residents. The instructor walked the residents
through the tasks, questioning them to ensure their under-
standing of the technique and the rationale for each step.
Residents were encouraged by the instructor to collaborate
with one another and work in groups in each setting.
Feedback
The theme of feedback was pervasive across all settings
and for each group and was both verbal and nonverbal. In
the IL group, feedback was infrequent regardless of the
setting. One resident stated, Sometimes we were told the
topics to learn, but during the practice we were on our
own. As the program progressed, residents began to solicit
some feedback from the instructor and educators; yet, it
was not always provided. In most cases, residents would
instead receive a lengthy lecture or a demonstration of the
specific task, during which the residents watched and asked
questions but did not participate. Feedback was not
spontaneously provided by either the instructor or resident
educators; however, positive feedback was sometimes given
when residents correctly answered questions. Residents
primarily worked independently, limiting the opportunity
for peer-to-peer feedback. The amount and type of
feedback varied from session to session and was dependent
on residents requests for feedback. Often, the instructor
would take over a task and complete it while providing
some explanation of the intricacies of the technique. One
resident explained, Many times (the instructor) put his
hands in and took over.
Conversely, in the SL group, feedback from the in-
structors and educators was consistently positive during
both the anatomy laboratory and surgical skills center
sessions. Feedback was continuous during the practicing of
111
surgical techniques and frequently occurred between resi-
dents in a collaborative manner. Demonstration and feed-
back were often complementary. As an example, when
practicing skin grafting, a resident asked, .once you cut
through, whats the next step? The instructor then
demonstrated the task, watched the resident perform it,
and then said, Thats very good, okay, well done. This
was a common occurrence in the SL cohort. The instructor
and educators also made efforts to identify incorrect
technique(s), on which they provided specific feedback to
explain why it was incorrect, then would demonstrate or
assist until the technique was performed accurately. The SL
instructor was described by several residents as . a
source for information and feedback, more like a mentor.
As the program progressed, more feedback came from
fellow residents than from the instructor and educators, and
peer-to-peer advice was solicited and provided on a regular
basis. Peer-to-peer interaction was omnipresent throughout
the program in the SL cohort.
Peer and instructor collaboration
All 3 independent researchers found that collaboration
between residents was distinctly different between groups.
The residents in the SL group were encouraged to work in
groups right from the beginning of the program, which in
turn fostered peer-to-peer collaboration, allowing for
assistance, advice, and feedback. These residents chose to
work in both small and large groups, depending on the task.
One resident noted, . (it) was more of a collaboration in
learning and trouble-shooting; happy to work and learn as a
team. If 2 or more residents could not answer a particular
question using their own resources, they then resorted to
asking the instructor or educator. The provision of advice
was commonly observed among residents in the SL group.
According to one of the residents, . it was a collabora-
tive process (and very helpful), since we established rapport
with peers. As the program progressed, residents in the SL
group began to assume the role of the teacher, during which
they would explain and demonstrate techniques to the
group, answer questions, and discuss objectives.
Immediately from the beginning of the TOBC course,
the IL residents worked independently instead of in groups,
limiting collaboration among residents. An IL resident
stated, (The instructors) guided us through, but we did
most of the procedures ourselves. Another noted, . it
was a mix of demonstration and doing it myself. Toward
the end of the TOBC, however, the IL residents began to
collaborate with one another more frequently but not
consistently. A resident explained, being able to bounce
ideas off each other (at the end), get advice from each
other; different people bring different strengths. it was
more collaboration. Most the IL residents agreed that the
instructor and educators became more hands-off as the
program progressed.
Collaboration between instructors and residents also
emerged in the field notes and exit interviews. This
112
occurred early in the SL group. The IL group, which
followed more of a lecture and demonstration-based pro-
tocol, did not demonstrate this type of collaboration until
late in the program when the residents became more
comfortable with the instructor, the educators, and their
peers. In stark contrast to the IL protocol, the SL residents
were encouraged to work in small groups, and dedicated
time for question and answer periods was set aside, both of
which fostered this collaboration. One SL resident ex-
plained, . having boot camp in a non-threatening
environment with great resources in instruction was great,
and (we) can learn at our own pace, learning from peers and
establishing a good support network with the instructors
and fellow residents. Because of the individual practice
nature of the IL format, collaboration with instructors and
peers was quite limited.
Self-efficacy
Self-efficacy, as evidenced by self-reports of resident
confidence, was not as profound in the IL group when
compared with the SL group. The lengthy lectures and the
taking over by the instructor during practice was a prevalent
concept during both the anatomy laboratory and the surgi-
cal skills center sessions for the IL group. The IL residents
found themselves doing more observing of procedures than
actually practicing the tasks, which reduced the amount of
time the residents had to practice and become more
competent in the assignments as set out by the objectives.
When one resident explained that the instructor took over
quite frequently, he or she imparted that taking over is not
what I wanted; I really wanted to do it. I can read it any
time, but this is my chance to actually do it. The hands-off
approach used with the SL group allowed the residents to
work together, independent of the instructor. This appeared
to boost the residents confidence and foster a sense of
autonomy, as they were able to complete tasks successfully
on their own, . its nice to be able to answer someones
questions correctly. it established confidence (among
peers) that way. Another SL resident explained that
(the educators) didnt sit there and lecture us and hover
over us all the timed(they) allowed us to experiment, until
we hit a moment where we have a question and (they) come
over to help us through and critique our technique until we
got it right.
Instructor exit interviews
The exit interviews with the 2 primary instructors also
indicated differences in how the participants were taught and
how they learned in both groups; however, many comments
were positive with regard to the overall outcomes of the
program. The SL instructor indicated that he tried to be a
facilitator as much as possible (in contrast to a traditional
apprenticeship-based instructor). He stated, I was quite
didactic in the beginning, since they (residents) didnt know
The American Journal of Surgery, Vol 209, No 1, January 2015
how to start or proceed; (but) later on they were pretty much
independent and collaborative. and I was less hands-on.
As far as independence in the SL group, the instructor
explained, If they had something they wanted to practice
again, they would go ahead with it; I would find that if I was
being too instructive, they would tell me to stay back a bit and
let them try it and if they ran into trouble they would ask for
me . it was a good balance and boosted their confidence.
Furthermore, the SL instructor considered the residents to be
light years ahead of people who didnt do the boot camp.
The primary role as described by the IL instructor was to be
both a guide and a source of information . my teaching
style (was) to teach and ask . I used a combination of
demonstrations and verbally guiding them . it was led by
me. Both instructors did express that the boot camp was
indeed a valuable program for all incoming orthopedic
residents, preparing them well for their first year as residents.
Comment
This research qualitatively examined differences in first-
year orthopedic residents learning based on 2 different
teaching paradigms: the traditional, IL style of teaching and
our novel, SL approach. Some of the themes that emerged
during the analysis were expected based on the pedagogic
designs, although some arose somewhat spontaneously. It
was clear that different styles of teaching during a
laboratory-based skills course can affect the learning pro-
cess and outcomes of technical and nontechnical skills and
interactions for first-year orthopedic residents. Based on the
session transcripts and the anecdotal evidence provided by
participants, the traditional apprenticeship-based IL model
did not foster as much peer-to-peer collaboration and
collaboration with their instructor when compared with
the SL method. The SL approach allowed for greater
resident autonomy and collaboration in a lower stress
environment as a hands-off methodology was used by the
instructor and senior resident educators. This led the SL-
group residents to view their instructor more as a mentor
and facilitator. With the new resident work hour restrictions
and the efforts to ensure all residents meet the CanMEDS
and other organizational competencies, an SLL paradigm
embedded within a surgical skills training program may be
an ideal option for residency programs.
The fact that the SL group was more collaborative and
demonstrated more peer-to-peer interactions than the IL
group is significant. Learning is enhanced in an interactive,
socially rich environment and that peer groups can serve as
significant sources of knowledge.28 The tendency of SL res-
idents to engage in peer assistance is also consistent with
one of the self-directed learning strategies described by
Zimmerman.29 Zimmermans29 research revealed that
high achieving and gifted students use such strategies as so-
cial sources of assistance more than their counterparts. Peer
learning is known to improve engagement, participation,
and attitude.24 Furthermore, when students work together
J. Hoogenes et al. Student-led learning
toward a shared goal and engage in open discussions, they
challenge each other to attain a higher level of thinking.24
As a result of this dynamic interactive learning process,
cooperative and peer-assisted learning are known to be
very effective tools for enhancing problem-solving abilities,
critical thinking, communication, collaboration, and team-
work skills.23 Notably, this would improve education in
the communicator and collaborator roles as delineated nature.36 One concern with the current shift toward
by the CanMEDS framework, ultimately impacting the re-
maining CanMEDS roles.
The finding that residents in the SL group felt much more
in control of their own learning and were more actively
involved in the learning process than residents in the IL group
is consistent with our previous observations. Active learning
strategies are believed to be effective by increasing trainees
motivation to learn and engagement in the process and by
fostering more positive attitudes.30 Moreover, active learners
are able to use a variety of individual strategies to amplify
their learning, such as self-appraisal, self-monitoring, and
goal setting.31 SL residents often did not wait for instructions
but rather explored the procedures as a group under their own
direction and revisited tasks if they felt it was required.
Research has shown that trainees learn most effectively
when they are afforded pedagogical space to experiment
and when given the freedom to access practice materials as
they wish.13,32,33 This student-centered approach is known collaborative, socially rich learning environment makes
to greatly enhance learning.31 Furthermore, active learning
strategies are known to help develop interpersonal and
problem-solving skills, as well as improve critical thinking
and leadership abilities.22,23,34 Thus, it follows that if we
are able to promote active learning through the use of an
SLL paradigm, we may be able to develop and refine a variety
of nontechnical skills in addition to improving the acquisition
of motor skills.
Our results suggest some parallels between SLL and the
widely-adopted problem-based learning (PBL) teaching
strategy. PBL is believed to be effective in part due to its
small group format and encourages students to work together
and engage in cooperative learning to reach their goals.35 Ed-
ucators are encouraged to act as facilitators and to allow for
greater student choice and autonomy.35 This is believed to
improve motivation, knowledge acquisition, and academic
performance. The training for the SLL educators before im-
plementation in the TOBC course included some of these
PBL constructs; both SLL and PBL are student-centered ap-
proaches emphasizing instructor facilitation. However, PBL
is traditionally structured as a tutorial session in which
learners work together in small groups to solve specially de-
signed cases or problems, focusing on developing trainees
problem-solving skills and content knowledge. Our SLL
paradigm aims to create a better learning environment to
help individual residents acquire a range of surgical skills
in the laboratory setting. Therefore, SLL and problem-
based learning appear to be different yet comparable ways
of achieving this type of an active, cooperative learning envi-
ronment, each with a slightly different overall structure and
implementation. The optimal strategy for a specific situation
113
may depend on the training context, the learners, and the set
of desired learning outcomes.
There has recently been a call to attention for the necessity
of professional identity development in surgical training,
especially with the emergence of CBE.20 Professional iden-
tity may be defined as ways of being and relating in profes-
sional contexts and is largely social and relational in
competency-based programs is that there may be an overem-
phasis on the attainment of measurable outcomes and a lack
of consideration for identity development.20 This situation
may be ameliorated by the implementation of an SLL para-
digm. Peers and other residents can serve as critical reference
groups for trainees, and they may be much more willing to
test out new roles among their peers than their instructors.37
Student empowerment is also important for this process, and
educators should afford trainees with pedagogic space to
reflect on and amalgamate developing identities.36 Interac-
tions with mentors and informal instruction are also impera-
tive to the development of medical professionalism.36
Although it is evident that immersion in the clinical environ-
ment is a vital part of this process,20 it can and should be
maximized during laboratory-based teaching sessions. The
ability of an SLL paradigm to lessen the formal role of the
instructor and promote interactions between peers in a
this technique better suited for instilling a sense of profes-
sional identity in our trainees than a traditional IL para-
digm.28,3840 Perhaps this explains anecdotal reports which
suggest that SL trainees are demonstrating more competence
and confidence in the operating room later on in clinical
training, although further examination is required.
Instructors and senior resident educators were trained to
either use the SLL approach or the traditional, instructor-
based approach during the TOBC program; however, it was
not feasible to monitor exactly how the teaching was
implemented; therefore, that is a potential drawback to the
analysis of this research. Had the instructors and educators
used similar teaching techniques, we would have likely
seen much less of a difference between how residents in
each group learned and their behaviors in each of the
training settings and during practice sessions. One limita-
tion of our study is that there may have been some
contamination between the SL and IL groups due to
residents interactions outside the anatomy laboratory and
surgical skills center; however, this aspect was largely out
of the control of the study staff. Another limitation may be
that of the differences in note taking among the research
assistants, thereby potentially introducing bias and leading
to differences in the way the transcripts were written and
subsequently analyzed.
Conclusions
This research has allowed us to start to explore some of the
mechanisms which give rise to the advantages of the SLL
114
paradigm that have been reported by new residents and their
supervising faculty. However, we note that our sample sizes
are small. Further work is clearly needed to truly understand
its long-term effect. SLL has potential to improve the
acquisition of technical skills and nontechnical skills and
may help promote the early formation of professional
identity in surgical trainees. This is of utmost importance
in an age where training is shifting to competency-based
frameworks and where many adverse events may be
attributed to deficiencies in nontechnical skills.21 When im-
plementing this approach, educators should also be mindful
of the fact that expert presence is essential for facilitating
the learning process, especially at the onset of training.
Although present, instructors must afford trainees pedagogic
space to explore and practice skills on their own accord. This
approach requires instructors to be properly trained as it
marks a departure from the traditional master-apprentice
model of teaching. As surgical education begins to rely
more heavily on simulation to supplement and enhance clin-
ical teaching, the implementation of a SLL paradigm may
help ensure that trainees are developing not only technical
skills but also the ancillary nontechnical skills that are
required for independent practice.
References
1. Hodges BD. A tea-steeping or i-Doc model for medical education?
Acad Med 2010;85:S3444.
2. Accreditation Council for Graduate Medical Education (ACGME).
Common Program Requirements. p. 122 Available at , https://www.
acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs
2013.pdf; 2013. Accessed May 5, 2014.
3. Bell RH, Biester TW, Tabuenca A, et al. Operative experience of res-
idents in US general surgery programs: a gap between expectation and
experience. Ann Surg 2009;249:71924.
4. Naik VN, Wong AK, Hamstra SJ. Review article: leading the future:
guiding two predominant paradigm shifts in medical education
through scholarship. Can J Anesth 2012;59:21323.
5. Frank JR, editor. The CanMEDS 2005 Physician Competency Frame-
work. Ottawa: The Royal College of Physicians and Surgeons of Can-
ada; 2005. p. 111.
6. Swing SR. The ACGME outcome project: retrospective and prospec-
tive. Med Teach 2007;29:64854.
7. McKee RF. The Intercollegiate Surgical Curriculum Programme
(ISCP). Surgery (Oxford) 2008;26:4116.
8. Harden RM, Crosby JR, Davis MH, et al. AMEE Guide No.14: outcome-
based education: part 5-from competency to meta-competency: a model
for the specification of learning outcomes. Med Teach 1999;21:54652.
9. Reznick RK, MacRae H. Teaching surgical skillsdchanges in the
wind. N Engl J Med 2006;355:26649.
10. Cook DA. Comparative effectiveness of instructional design features
in simulation-based education: systematic review and meta-analysis.
Med Teach 2013;35:e86798.
11. Brydges R, Dubrowski A, Regehr G. A new concept of unsupervised
learning: directed self-guided learning in the health professions. Acad
Med 2010;85:S4955.
12. Ericsson KA. An expert-performance perspective of research on medical
expertise: the study of clinical performance. Med Educ 2007;41:112430.
13. Brydges R, Carnahan H, Safir O, et al. How effective is self-guided
learning of clinical technical skills? Its all about process. Med Educ
2009;43:50715.
The American Journal of Surgery, Vol 209, No 1, January 2015
14. Murad MH, Coto-Yglesias F, Varkey P, et al. The effectiveness of self-
directed learning in health professions education: a systematic review.
Med Educ 2010;44:105768.
15. Butler DL, Winne PH. Feedback and self-regulated learning: a theoret-
ical synthesis. Rev Educ Res 1995;65:24581.
16. Sonnadara RR, Garbedian S, Safir O, et al. Toronto Orthopaedic Boot
Camp III: examining the efficacy of student-regulated learning during
an intensive laboratory-based surgical skills course. Surgery 2013;154:
2933.
17. Zimmerman BJ. Attaining self-regulation: a social cognitive perspec-
tive. In: Boekaerts M, Pintrich PR, Zeidner M, editors. Handbook of
Self-regulation. San Diego: Academic Press; 2000. p. 1339.
18. Sonnadara RR, van Vilet A, Safir O, et al. Orthopedic boot camp:
examining the effectiveness of an intensive surgical skills course. Sur-
gery 2011;149:7459.
19. Sonnadara RR, Garbedian S, Safir O, et al. Orthopaedic Boot Camp II:
examining the retention rates of an intensive surgical skills course.
Surgery 2012;151:8037.
20. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough:
integrating identity formation into the medical education discourse.
Acad Med 2012;87:118590.
21. Sharma B, Mishra A, Aggarwal R, et al. Non-technical skills assess-
ment in surgery. Surg Oncol 2010;20:16977.
22. Flin RH, OConnor P, Crichton DM. Safety at the Sharp End: A Guide to
Non-technical Skills. Hampshire: Ashgate Publishing, Ltd; 2008. p. 340.
23. Poindexter S. Assessing active alternatives for teaching programming.
JITE-Research 2003;2:25765.
24. Topping KJ. Trends in peer learning. Educ Psychol 2005;25:63145.
25. Sandelowski M. Focus on research methodsdwhatever happened to
qualitative description? Res Nurs Health 2000;23:33440.
26. Ferguson P, Kraemer W, Nousiainen M, et al. Three-year experience
with an innovative modular competency-based curriculum for ortho-
paedic training. J Bone Joint Surg Am 2013;95. e166:16.
27. Britten N. Qualitative interviews in medical research. BMJ 1995;311:
2513.
28. Sandars J, Homer M, Pell G, et al. Web 2.0 and social software: the
medical student way of e-learning. Med Teach 2008;30:30812.
29. Zimmerman B, Martinez-Pons M. Student differences in self-regulated
learning: relating grade, sex, and giftedness to self-efficacy and strat-
egy use. J Educ Psychol 1990;82:519.
30. Michael J. Wheres the evidence that active learning works? Adv
Physiol Educ 2006;30:15967.
31. Zimmerman BJ. Self-regulated learning and academic achievement: an
overview. Educ Psychol 1990;25:317.
32. Keetch KM, Lee TD. The effect of self-regulated and experimenter-
imposed practice schedules on motor learning for tasks of varying dif-
ficulty. Res Q Exerc Sport 2007;78:47686.
33. Jowett N, LeBlanc V, Xeroulis G, et al. Surgical skill acquisition with
self-directed practice using computer-based video training. Am J Surg
2007;193:23742.
34. Burbach ME, Matkin GS, Fritz SM. Teaching critical thinking in an
introductory leadership course utilizing active learning strategies: a
confirmatory study. Coll Student J 2004;38:48293.
35. Albanese M. Problem-based learning: why curricula are likely to show
little effect on knowledge and clinical skills. Med Educ 2000;34:72938.
36. Goldie J. The formation of professional identity in medical students:
considerations for educators. Med Teach 2012;34:e6418.
37. Shuval JT. From boy to colleague: processes of role transforma-
tion in professional socialization. Soc Sci Med 1975;9:41320.
38. Varga-Atkins T, Dangerfield P, Brigden D. Developing professionalism
through the use of wikis: a study with first-year undergraduate medical
students. Med Teach 2010;32:8249.
39. Cruess RL, Cruess SR. Teaching professionalism: general principles.
Med Teach 2006;28:2058.
40. Irby DM, Cooke M, OBrien BC. Calls for reform of medical educa-
tion by the Carnegie Foundation for the Advancement of Teaching:
1910 and 2010. Acad Med 2010;85:2207.