Audio Diaries Reveal What Shapes Surgical Residents’ Learning in the Clinic

Every surgeon remembers the first time a patient’s life sat in their hands, but the long, messy process of becoming a surgeon has remained largely invisible to researchers. Now a team in Pakistan has opened a rare window into that hidden curriculum. In a qualitative study published in Global Surgical Education, the Journal of the Association for Surgical Education, researchers asked eleven oral and maxillofacial surgery residents to record reflective audio diaries about their day-to-day learning in the hospital. The resulting thirty-three recordings, transcribed and analysed thematically, paint a vivid picture of how future surgeons actually learn: not in lecture halls, but in the crowded, high-pressure environment of the clinical workplace, where every extraction, every ward round and every complication carries an educational charge.

The study, led by Tariq Ahmad and Muslim Khan of Khyber College of Dentistry in Peshawar, together with Brekhna Jamil of the Institute of Health Professions Education at Khyber Medical University and Muhammad Shahzad of Khyber Medical University and Zarqa University in Jordan, focused on postgraduate residents enrolled in training programmes overseen by the College of Physicians and Surgeons Pakistan. Oral and maxillofacial surgery is a demanding specialty that bridges dentistry and medicine, requiring trainees to master everything from complex dentoalveolar procedures to the management of facial trauma, tumours and reconstructive surgery. Yet the researchers noted that the learning experiences of these residents, and the factors that help or hinder their development, had received surprisingly little systematic attention, particularly in low- and middle-income countries where most of the world’s surgical training actually takes place.

The methodological choice is what makes the study distinctive. Rather than relying on retrospective interviews, which are notoriously vulnerable to memory bias and to what participants think researchers want to hear, the team used the audio-diary technique described in the Association for Medical Education in Europe’s Guide No. 144. Each resident recorded three reflective audio diaries capturing their experiences close to the moment they occurred. This approach, grounded in experiential learning theory associated with David Kolb and in the sociocultural ideas of Lev Vygotsky, allows researchers to capture learning as it unfolds in real time, including the emotional texture of clinical work that formal assessments rarely register. The diaries were then transcribed verbatim and subjected to thematic analysis, a qualitative method that identifies recurring patterns of meaning across the corpus of narratives.

The central finding is that workplace learning in this surgical setting is a multifaceted process shaped principally by three forces: clinical exposure, collaboration, and a supportive organisational environment. Clinical exposure emerged as the engine of learning, with residents describing how hands-on encounters with patients, from routine third molar extractions under local anaesthesia to major oncological resections, provided the raw material from which surgical competence is built. This aligns with decades of research on informal workplace learning, notably Michael Eraut’s work showing that much professional knowledge is acquired incidentally, through participation rather than instruction. But exposure alone was not enough. The residents’ accounts repeatedly emphasised that learning deepened when it was embedded in collaborative practice, where colleagues discussed cases, shared techniques and debriefed after difficult procedures.

The study identified a clear set of enablers that residents said made their learning possible. The overall work environment came first: hospitals where the atmosphere encouraged questions and permitted supervised autonomy transformed routine service work into educational opportunity. Supervisor support was another decisive factor. When consultants took time to explain the reasoning behind a surgical decision, demonstrated techniques step by step, or gradually entrusted residents with greater responsibility, trainees reported accelerated growth in both skill and confidence. This resonates strongly with the international literature on entrustment, including studies showing that faculty willingness to grant autonomy in the operating room is one of the strongest predictors of resident development. Peer support formed a third pillar, with senior residents functioning as what Vygotskian theory would call more knowledgeable others, scaffolding juniors through procedures just beyond their independent capability.

Perhaps most strikingly, the residents highlighted the availability of learning resources and support staff as a critical enabler, a finding that carries particular weight in resource-constrained health systems. Adequate nursing assistance, functioning equipment, access to journals and simulation facilities, and sufficient staffing to allow time for teaching all shaped whether a clinical day became a learning day or merely a shift to be survived. The researchers frame these findings within the concept of self-regulated learning, the process by which trainees set goals, monitor their own performance and adjust strategies. Self-regulation, the literature suggests, flourishes only when the workplace provides the psychological safety and material conditions that make deliberate practice possible. In surgical education, where the stakes of error are measured in patient harm, the environment is not a backdrop to learning but an active ingredient in it.

Against these enablers, the diaries recorded a darker catalogue of barriers. Excessive workload was the most frequently cited obstacle. Residents described rosters so demanding that fatigue eroded both their capacity to absorb teaching and their motivation to reflect on cases. This finding echoes a growing global literature on burnout among postgraduate medical trainees, including a systematic review published in CMAJ Open reporting substantial prevalence of burnout worldwide, and earlier Pakistani studies documenting burnout among surgical residents in the country’s public hospitals. The second major barrier was the lack of support staff, which forced residents to divert energy from learning into administrative and menial tasks, a phenomenon well documented in workplace-based studies from other lower-middle-income settings. The third barrier, fear of unexpected outcomes, deserves particular attention: residents described how anxiety about complications, and about the professional and emotional consequences of adverse events, made them hesitant to take on cases that would stretch their abilities.

This fear finding connects to one of the most important tensions in surgical training worldwide: the balance between patient safety and trainee autonomy. Research on trust in clinical education, including work by Hauer, Ten Cate and colleagues, has shown that supervisors calibrate the independence they grant based on perceived trainee competence, and that trainees in turn regulate their own participation based on their confidence and their reading of the supervisor’s trust. When fear of complications dominates, this delicate feedback loop can freeze, producing residents who remain passive observers far longer than their abilities warrant. The Pakistani study suggests that in settings with limited support staff and high patient volumes, this dynamic may be amplified, making structured supervision and psychological support after adverse events not luxuries but prerequisites for effective training.

The authors argue that understanding these enablers and barriers has direct practical value for the organisations that run postgraduate residency programmes in oral and maxillofacial surgery. By mapping where learning flourishes and where it stalls, programme directors can design more supportive and structured clinical training: protecting teaching time within heavy workloads, ensuring adequate staffing so residents are not consumed by non-educational tasks, training supervisors in feedback and entrustment, and building systems that help residents process complications constructively rather than through fear. The audio-diary method itself, the team suggests, could be adopted more widely, both as a research tool and as a reflective practice instrument for trainees, since recording regular reflections is known to deepen metacognition and professional identity formation.

The study’s significance extends well beyond one specialty or one country. With the global health workforce facing projected shortfalls of millions of workers by 2030, according to analyses in BMJ Global Health, most surgical training in the coming decades will happen in exactly the kind of resource-limited environments this study examined. Understanding how residents learn in those environments, and what institutions can do to multiply the enablers and dismantle the barriers, is therefore a matter of global health equity as much as educational theory. The voices captured in these thirty-three audio diaries, recorded between a resident and a recorder in the quiet after a long clinical day, offer a reminder that the making of a surgeon is a social and organisational achievement, not merely an individual one, and that every hospital, through its culture and its choices, is either building surgeons or wearing them down.

Subject of Research: Workplace-based clinical learning experiences of oral and maxillofacial surgery residents in Pakistan

Article Title: Exploring clinical workplace learning among oral and maxillofacial surgery residents: a qualitative audio diary study

Article References: Ahmad, T., Jamil, B., Khan, M., & Shahzad, M. (2026). Exploring clinical workplace learning among oral and maxillofacial surgery residents: a qualitative audio diary study. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 144. https://doi.org/10.1007/s44186-026-00549-9

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00549-9

Keywords: oral and maxillofacial surgery, surgical education, workplace learning, audio diaries, residency training, qualitative research, supervision, burnout, self-regulated learning, Pakistan, medical education, clinical exposure