How a 1990s Framework Is Rewriting the Science of Training Surgeons

Surgical education has quietly become one of the most dynamic corners of academic medicine, and a new opinion piece published in Global Surgical Education, the journal of the Association for Surgical Education, argues that the field’s future depends on understanding its past. Researchers Marquise D. Singleterry, Jamila K. Picart, and Gurjit Sandhu of the University of Michigan’s Center for Surgical Training and Research trace three decades of scholarship and offer a conceptual roadmap for researchers navigating an era reshaped by competency-based training and artificial intelligence. Their central claim is striking: the tools needed to modernize how surgeons are trained were laid out more than thirty years ago, in a framework most people outside academia have never heard of.

That framework comes from Ernest Boyer, the former US Commissioner of Education who, in 1990, challenged the graduate professional community to reconsider what counts as scholarship. Boyer argued that the traditional, singular view of scholarship, essentially the generation of new knowledge through scientific inquiry, was too narrow for the modern academy. He proposed instead that scholarship comprises four interdependent components: discovery, integration, application, and teaching. The Michigan authors contend that this inclusive definition paved the way for surgical education research to be recognized as legitimate scholarship rather than a hobby for clinicians with spare time. Just as a changing campus environment pushed Boyer to rethink scholarship, they write, today’s surgical education community faces a similar inflection point.

The momentum behind the field is measurable. Within the last decade, membership of the Association for Surgical Education has more than doubled, now exceeding 1,500 members. Two major forces are driving that growth. The first is the transition to competency-based medical education, or CBME, which replaces time-based training metrics with demonstrated ability. The second is technological: advances in artificial intelligence are beginning to augment everything from simulation feedback to personalized instruction. The authors argue that quality surgical education research is grounded in historical context, enhanced by modern innovation, and tempered by dedication to evidence-based practices, a triad that echoes Boyer’s insistence that scholarship must be both rigorous and useful.

What exactly is surgical education research? The authors define it as the systematic, scholarly study of how surgical training is taught, how it is learned, and how those processes ultimately affect patient care. The intersection of learners, educators, and patients makes the field unusually rich, though investigating an environment while simultaneously working inside it can feel reflexive. The authors embrace that tension, arguing that trainee and faculty stakeholders offer a critical, situated perspective that lends authenticity and applicability to the research. Observation and experience alone, they caution, do not produce expertise; insight must be paired with rigorous research principles to improve educational practices, systems, and learning environments.

Each of Boyer’s four components, the authors show, has produced landmark work in surgery. The scholarship of discovery, the generation of new knowledge, is exemplified by the concept of Entrustable Professional Activities, or EPAs, which shifted the determination of trainee competence toward whether a supervisor would trust a resident to perform a task unsupervised. The scholarship of integration, connecting knowledge across disciplines, is illustrated by work arguing that CBME cannot exist without continuous and comprehensive assessment, drawing on cognitive psychology, organizational behavior, and psychometrics. The scholarship of application, engaging inquiry with the real world, is perhaps the most intuitive for surgeons: validation studies of simulation-based training became essential when duty hour reform forced educators to innovate beyond the conventional operating room. Finally, the scholarship of teaching, subjecting instructional methods to peer review, was revolutionary in a profession where teaching had long escaped systematic analysis; early studies confirmed that resident evaluations were highly reliable predictors of both faculty teaching activity and clinical practice.

The authors organize nearly thirty years of scholarship into six domains, each showing a trajectory from foundational work to contemporary refinement. In assessment, the Objective Structured Assessment of Technical Skill, introduced in 1997, gave surgical residency its first structured, reliable method for measuring technical skill, signaling a shift toward objective, performance-based evaluation. Nearly two decades later, the Zwisch scale operationalized levels of intraoperative supervision and autonomy, extending that rigor to the operating room itself. In curriculum and instruction, the Briefing, Intraoperative teaching, Debriefing model provided a structured framework for teaching and reflection during surgery, while more recent work has linked feedback quality and the organization of practice directly to skill acquisition, reflecting a move toward evidence-informed curricular design.

Simulation and technology tell perhaps the most compelling story. A simulation-based mastery learning program demonstrably increased residents’ skill at inserting central venous catheters and, critically, reduced complications during actual patient care, providing hard evidence that training in the laboratory translates to the bedside. A more recent randomized clinical trial found that integrating artificial intelligence to augment personalized expert instruction further improved surgical simulation performance, marking the field’s expansion from basic skills training to advanced, technology-enhanced education. In continuing professional development, studies identifying specific operating room teaching behaviors, such as calmness and hands-on guidance, that correlate strongly with resident learning have evolved into structured interventions like OpTrust, an educational bundle that produced measurable improvements in teaching, learning, and faculty-resident trust.

The remaining domains broaden the field’s moral scope. Research on well-being established that burnout among American surgeons is linked to increased medical errors, and recent work has shown that disparities in mentorship affect resident education and wellness. In diversity, equity, and inclusion, early studies identified structural, cultural, and perception-based barriers deterring women from entering surgery, while a more recent analysis of surgical subspecialty training found racial and sex disparities in resident attrition. The authors note that scholarship here has expanded from examining individual and group barriers to systemic examination of recruitment and retention, a maturation they see as essential to the field’s credibility.

For researchers entering the field, the authors prescribe a disciplined methodological approach. It begins with formulating good research questions grounded in real problems encountered in the learning environment, keeping a running record of questions, ideas, and concerns as they arise. Researchers should map what the existing literature says, identifying gaps that may affect learning, teaching, performance, or patient care, and look beyond medicine to psychology, sociology, and epidemiology for framing. Strong questions, they remind readers, should satisfy the FINER criteria: feasible, interesting, novel, ethical, and relevant. Methodological variety is encouraged, but only with a clear understanding of each method’s limitations, careful identification and mitigation of bias, and consistent adherence to professional ethical standards. Modern solutions, including improved resource access, involving learners at all levels, national collaboration, and systematically integrating AI research tools, can offset the labor intensity that once discouraged surgical education studies.

The road ahead is not without obstacles. The authors acknowledge ongoing challenges in access to resources, mentorship availability, and inconsistent recognition of surgical education scholarship in promotion decisions made by department leadership. Yet the infrastructure for growth is substantial: several prominent peer-reviewed journals dedicated to surgical education now serve as reservoirs for evidence-based work, and communities of practice such as the Center for Surgical Training and Research, the Collaboration of Surgical Education Fellows, and the Surgery Education Research Fellowship connect mentees and mentors while providing guidance on methodology and strategy. What sustains the community, the authors conclude, is not the pace of progress but its stakes: the readiness of surgical trainees, the effectiveness of educators, and, ultimately, the outcomes of the patients in their hands.

Subject of Research: Historical and conceptual analysis of surgical education research using Boyer's scholarship framework

Article Title: Surgical education research: approaching a historic topic with a new lens

Article References: Singleterry, M. D., Picart, J. K., & Sandhu, G. (2026). Surgical education research: approaching a historic topic with a new lens. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 123. https://doi.org/10.1007/s44186-026-00524-4

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00524-4

Keywords: surgical education, medical education, Ernest Boyer, competency-based medical education, simulation training, artificial intelligence, Entrustable Professional Activities, assessment, well-being, diversity equity inclusion, research methodology, Association for Surgical Education