The study, published in Global Surgical Education, the journal of the Association for Surgical Education, set out to answer a deceptively simple question: can a validated instrument for tracking operative trust, originally built for general surgery, work in an environment where every case is long, complex, and uniformly life-or-death? The answer, according to the research team led by Megan L. Schultz and Gurjit Sandhu, is a resounding yes—and the data they gathered reveal just how tightly trust and hands-on opportunity are linked.

The stakes could hardly be higher. Cardiac surgery training is in trouble. Work-hour restrictions, heightened patient safety concerns, and growing scrutiny of surgical outcomes have all chipped away at the traditional model of graded responsibility, in which trainees earn progressively more independence as their skills mature. Meanwhile, the patients themselves have changed: advances in interventional cardiology mean that the straightforward teaching cases of previous generations are increasingly rare, and those who do reach the operating table carry more comorbidities than ever. Cardiac surgery, as a leader in outcomes transparency, has felt these pressures acutely.

The consequences are measurable. Many cardiothoracic trainees now graduate without routinely performing common procedures such as off-pump coronary artery bypass grafting or mitral valve repair. More than half of recent graduates report insufficient exposure to minimally invasive, robotic, and congenital cardiac operations. In 2024, more than a quarter of examinees failed the thoracic oral board certification exam on their first attempt—the highest failure rate in more than a decade. Layered on top of this is a looming workforce crisis: the Health Resources and Services Administration projects a 34 percent shortage of cardiothoracic surgeons in the United States by 2037. Against that backdrop, understanding how trust is built—or withheld—in the operating room becomes a matter of national workforce planning, not just pedagogy.

The instrument at the heart of the study is called OpTrust, a tool previously validated in general, vascular, and plastic surgery. It measures two intertwined phenomena: faculty entrustment, the willingness of the attending surgeon to delegate, and trainee entrustability, the behaviors the trainee displays that warrant that delegation. Raters score five behavioral domains—the types of questions asked, the operative plan, instruction, problem solving, and trainee leadership—on a scale from 1, indicating low entrustability, to 4, indicating full entrustability. Because prior work has shown the five domains collapse into a single construct, the scores are averaged into one number for each surgeon and trainee, then combined into a total dyad score ranging from 1 to 7, where 7 means the trainee operated autonomously.

What makes the new work distinctive is the Cardiac OpTrust supplement, a specialty-specific addition that grounds those abstract trust scores in fifteen concrete surgical benchmarks drawn from the shared sequence of nearly every cardiac operation using cardiopulmonary bypass. The benchmarks run from incision and sternotomy through internal mammary artery harvest, cannulation stitches, heparin administration, aortic cannulation, initiation of bypass, application and removal of the cross-clamp, cessation of bypass, protamine administration, decannulation, chest tube placement, and closure. For each benchmark, a trained third-party observer simply recorded who performed it: the faculty surgeon or the trainee. That binary record, stacked against the trust scores, turns the rhythm of a cardiac case into a granular map of autonomy.

Between November 2022 and June 2023, trained research assistants observed forty-nine elective cardiac operations at the University of Michigan, a large quaternary care academic medical center. The raters underwent standardized training and had to achieve at least 80 percent interrater reliability before collecting data independently. They observed from incision until the attending surgeon left the room, scoring faculty and trainees simultaneously but independently. The observed cases included twenty mitral or tricuspid valve repairs or replacements, twenty aortic valve or aortic root operations, eight coronary bypass grafting cases, and one combined bypass and mitral repair, generating scores for twenty-six unique faculty-trainee pairings drawn from twelve trainees and seven attending surgeons.

The results were strikingly consistent. Mean faculty entrustment was 2.46 on the four-point scale, mean trainee entrustability 2.47, and mean total dyad entrustment 3.93 on the seven-point scale, with trainees completing an average of 8.33 of the fifteen benchmarks per case. Crucially, entrustment scores were significantly higher for benchmarks the trainee completed than for those the attending kept. Spearman’s rank correlation confirmed strong positive associations between trainee benchmark completion and faculty entrustment, trainee entrustability, and total entrustment, with correlation coefficients of 0.66, 0.62, and 0.65 respectively.

Poisson regression quantified the relationship with even sharper precision. Each one-unit increase in faculty entrustment corresponded to a 32 percent increase in the number of benchmarks performed by the trainee, rising from an expected 5.36 benchmarks at low entrustment to 12.61 at full entrustment. Each unit increase in trainee entrustability behaviors predicted a 36 percent increase, from 5.17 to 13.00 benchmarks. And each unit increase in total dyad entrustment predicted a 16 percent increase, from 5.17 to 13.02. All associations were statistically significant at p less than 0.001. In plain terms: when trust goes up, the scalpel changes hands far more often.

Two benchmarks—protamine administration and cessation of cardiopulmonary bypass—did not reach statistical significance, though they followed the same trend. The authors note that these two tasks uniquely capture leadership and team management rather than pure technical skill, hinting at a fascinating distinction: entrusting a trainee to sew may be psychologically different from entrusting a trainee to direct the perfusionist, anesthesiologist, and nurses through the delicate transition off the heart-lung machine. Whether the principles of entrustment extend to these so-called soft skills remains an open question for future research.

The study’s limitations are candidly acknowledged. It was a single-institution pilot, so variability across cases, participants, and centers may shape how Cardiac OpTrust performs elsewhere. All faculty observed were male, reflecting the composition of the department at the time, while 51 percent of trainees were female—programs with different demographics may show different patterns. The tool also demands significant human resources, since it relies on independent raters physically present in the operating room. That investment, however, buys something self-report tools like SIMPL and Zwisch cannot: real-time, third-party observation free of recall bias. Previous work suggests the observer’s presence does not disrupt the operative experience, and the Hawthorne effect, while impossible to eliminate entirely, appears limited.

There is also an important conceptual caveat: OpTrust measures entrustment, not technical proficiency. A trainee may be handed tasks without being competent, or possess skill without being granted autonomy. The binary benchmark design records who performed each step, not how well. Still, because greater entrustment has been linked to operative performance in prior studies, optimizing trust in the cardiac operating room may yield tangible benefits for trainee competency and confidence. The benchmarks also deliberately exclude skills performed during the cross-clamp period, such as distal anastomoses in bypass grafting, since the pilot’s case volume was insufficient to draw meaningful conclusions about case-specific techniques; future iterations may add them.

The timing of this work is significant for structural reasons as well. Accredited general surgery programs have already integrated Entrustable Professional Activities into their curricula, vascular surgery programs are following, and cardiothoracic programs will likely face the same transition toward competency-based training soon. Tools like Cardiac OpTrust could provide the measurement backbone for that shift, replacing crude case counts with nuanced, behaviorally anchored assessments of when and why trainees are actually allowed to operate.

For now, the message from Ann Arbor is both simple and quietly radical: trust in the operating room is not an ineffable chemistry but an observable, countable phenomenon—and it can be studied, taught, and perhaps deliberately cultivated. As the authors argue, trainees can even use the OpTrust behavioral descriptions as a roadmap, incorporating the specific behaviors that signal readiness for greater independence. With further multi-center validation, the moment-by-moment choreography of trust in the cardiac operating room may finally become something educators can see, measure, and improve—one sternotomy, one cannulation, one cross-clamp at a time.

Subject of Research: Measuring intraoperative entrustment and trainee autonomy in cardiac surgery operating rooms

Article Title: Understanding and measuring intraoperative entrustment in the cardiac surgery operating room

Article References: Schultz, M. L., Theall, A. C. P., Ozuna-Harrison, R., Buchanan, D., Tubbs, D., Evans, J., Matusko, N., Bolling, S. F., & Sandhu, G. (2026). Understanding and measuring intraoperative entrustment in the cardiac surgery operating room. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 193. https://doi.org/10.1007/s44186-026-00595-3

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00595-3

Keywords: cardiac surgery, surgical education, entrustment, trainee autonomy, OpTrust, operating room, cardiopulmonary bypass, competency-based training, surgical benchmarks, faculty-trainee dyad, psychometrics, workforce shortage

The original article by Jenkins and colleagues drew on a comparison that has circulated in medical education circles for years: commercial and military aviation invests enormous resources in structured, simulation-heavy, competency-based training, and aviation has achieved remarkable safety records as a result. Surgical training, by contrast, has historically depended on an apprenticeship model in which trainees learn by doing under supervision in the operating theatre. The aviation argument is straightforward in principle. Pilots are not permitted to learn critical manoeuvres for the first time with passengers on board. They progress through ground school, simulators, dual-control instruction and graduated solo experience, with every stage assessed against defined standards before advancement. Surgery, the argument goes, should aspire to the same rigor, and simulation should occupy a far larger share of the training pathway than it currently does.

Swain, Denniss and Cooper are unusually well placed to test that argument. Swain works at the Academic Department of Military Surgery and Trauma at the Royal Centre for Defence Medicine in Birmingham and is also affiliated with the Department of Learning, Informatics, Management and Ethics at the Karolinska Institutet in Stockholm, a combination that bridges operative practice and formal educational science. Denniss serves with 845 Naval Air Squadron at Royal Naval Air Station Yeovilton, giving the response direct access to the cockpit-side perspective that the original article invoked. Cooper brings experience from the Regional Occupational Health Team Bulford and the Academic Department of Military General Practice, adding a medical workforce and occupational health dimension that is often missing from training debates. Together they represent exactly the kind of cross-disciplinary triangulation that the aviation-surgery comparison demands.

The technical heart of the discussion concerns how competency is defined, measured and maintained. In naval aviation, training follows a syllabus in which each flight exercise has defined objectives, and instructors grade performance against standardized criteria. Progression is not a function of hours logged alone but of demonstrated proficiency, and critical skills are revalidated periodically. Surgical training in the United Kingdom follows a national structured competency-based pathway managed by NHS England and the four surgical Royal Colleges, with progression monitored through the Intercollegiate Surgical Curriculum Programme. The ISCP framework defines assessment and feedback mechanisms that are, on paper, not so different from aviation’s structured grading. The respondents’ letter implicitly probes the gap between that paper structure and the lived reality of training, where case availability, service pressures and rota demands can shape operative experience in ways no syllabus intends.

One of the most consequential concepts in this debate is skill decay, the gradual erosion of learned performance when a skill is not practised. Stansfield and Tai addressed this directly in BMJ Military Health, writing about surgical skill decay in what they call the contingency era, a period in which military surgeons may go long stretches between high-acuity operative cases. The problem has a precise aviation parallel: pilots who do not fly regularly must complete currency requirements and simulator refresher sessions before returning to duty, because the psychomotor and decision-making elements of flying degrade measurably with disuse. For surgeons, especially those in military or low-volume settings, the same decay dynamics apply to complex operative skills, yet the systems for detecting and correcting decay are far less formalized. Simulation offers a partial answer, allowing deliberate practice of rare and high-risk procedures without patient exposure.

The evidence base for simulation in surgical education has grown substantially over the past two decades. Aggarwal and colleagues, writing in BMJ Quality and Safety, synthesized the case for training and simulation for patient safety, arguing that simulated environments allow teams and individuals to rehearse technical and non-technical skills, from instrument handling to crisis communication, in conditions where errors carry no human cost. High-fidelity simulators can reproduce tissue handling, bleeding scenarios and equipment failures, while virtual reality platforms track metrics such as economy of motion and error rates that provide objective performance data. McGhee’s recent doctoral work on surgical technology faculty perceptions of high-fidelity simulation adds a practical layer, examining how the educators who run these programs view their value and their limitations. The respondents’ letter situates itself within this evidence landscape, and the aviation comparison sharpens the point: aviation did not adopt simulation because it was fashionable, but because decades of accident analysis showed that errors made in training carried over into operations, and that rehearsal in a safe environment prevented them.

Yet the aviation analogy has limits that a naval aviator himself would be the first to acknowledge, and Denniss’s involvement in the response gives that acknowledgment weight. Aircraft are engineered systems with standardized cockpits, quantified performance envelopes and near-complete environmental control. Patients are not. Anatomical variation, tissue quality, comorbidity and intraoperative surprise introduce variability that no simulator fully reproduces, and the surgeon’s task includes continuous intraoperative reassessment that has no clean equivalent in flying a certified airframe. Moreover, aviation’s safety gains rest not only on training but on an entire ecosystem: mandatory incident reporting, just-culture investigation, crew resource management, and checklists enforced by regulation. Surgery has imported some of these elements, most famously the surgical safety checklist, but importing training structure alone, without the surrounding safety culture, would capture only part of what makes aviation safe.

There is also a cultural dimension to how trainees learn from error, and this is where the letter’s occupational health perspective becomes relevant. Lee and colleagues, writing in Global Surgical Education, examined how individual, cultural and systems factors shape surgical residents’ experience with medical errors and their ability to learn from mistakes. Aviation’s non-punitive reporting culture, in which pilots can disclose errors without automatic career consequences, contrasts with surgical environments where error discussion can still carry stigma. A trainee who fears blame will conceal mistakes, and concealed mistakes cannot become teaching moments. Building educational systems that treat error as data rather than as failure is arguably a deeper lesson from aviation than any simulator syllabus, and it requires engagement from the occupational health and wellbeing structures that Cooper’s affiliation represents.

The timing of this exchange matters. Surgical training worldwide faces converging pressures: reduced working hours, financial constraints on theatre time, rising subspecialization, and, in military contexts, operational tempo patterns that can leave surgeons case-starved between deployments. Simulation-based and competency-based training are often proposed as solutions, but they carry costs of their own, in equipment, faculty time and curriculum redesign. The value of the aviation comparison is that it offers a tested template for allocating scarce training resources: identify the highest-risk skills, build structured rehearsal for them, assess against explicit standards, and revalidate periodically. The respondents’ letter, by bringing a surgeon’s, a flying doctor’s and a pilot’s perspectives into a single conversation, models the kind of cross-professional dialogue needed to adapt that template intelligently rather than transplant it wholesale.

What emerges from the exchange is less a verdict than an agenda. The original article by Jenkins and colleagues asked whether surgical training should look more like naval aviation training. The response from Swain, Denniss and Cooper, published as a letter in Global Surgical Education with the backing of the Association for Surgical Education’s journal, suggests the question is worth taking seriously precisely because the two professions share the same fundamental challenge: producing operators who perform rare, high-stakes procedures safely under pressure, with training systems that must be efficient, evidence-based and honest about human fallibility. As surgical education moves further into simulation, virtual reality and structured competency assessment, the aviation world’s hard-won lessons about currency, standardization and safety culture will remain a reference point, and letters like this one ensure the borrowing is done critically, by people who have sat on both sides of the cockpit and the operating table.

Subject of Research: Cross-disciplinary comparison of naval aviation training methods and surgical education, including simulation, competency assessment and skill decay

Article Title: A surgeon, a flying doctor and a pilot’s response to Jenkins’ et al. “a naval aviators’ view of surgical training”

Article References: Swain, C., Denniss, J., & Cooper, K. (2026). A surgeon, a flying doctor and a pilot’s response to Jenkins’ et al. “a naval aviators’ view of surgical training”. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 126. https://doi.org/10.1007/s44186-026-00529-z

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00529-z

Keywords: surgical education, naval aviation, simulation-based training, skill decay, competency-based training, military surgery, medical errors, patient safety, Intercollegiate Surgical Curriculum Programme, virtual reality training, Royal Navy, training reform

The research, published in BMC Plastic and Reconstructive Surgery, emerged from a persistent problem. Microsurgical training programs have expanded internationally since Robert Acland established one of the first dedicated microsurgical training laboratories at the University of Louisville in 1976, but they vary dramatically in duration, equipment, trainee-to-instructor ratios, model selection, and assessment methods. Surveys of United States plastic surgery residency programs suggest that formalized curricula are less common than general exposure claims would imply. Against this backdrop, most microsurgery instructors develop their teaching style informally, through repetition and observation, with little deliberate preparation for the distinctly different skill set that teaching demands.

Effective microsurgical instruction requires far more than technical mastery, the Columbia team argues. Instructors must demonstrate procedures clearly under the operating microscope, diagnose learner errors in real time, adapt explanations to individual needs, calibrate constructive feedback, and sequence skill progression appropriately, all while maintaining a supportive learning environment. A surgeon may be able to perform a flawless microvascular anastomosis yet struggle to break that maneuver into teachable steps for a novice. The MTRL program was designed to close that gap by making the transition from doing microsurgery to teaching microsurgery explicit, structured, and open to reflection.

The curriculum’s development rested on three pillars. First, the investigators conducted a structured review of the microsurgical education literature, using databases including PubMed, ScienceDirect, and Scopus to trace the evolution of training strategies, models, and technologies; the findings are reported in a companion narrative review. Second, they aligned the program with published international recommendations from the International Microsurgery Simulation Society, the European Society for Surgical Research, the International Society for Experimental Microsurgery, and the European Union of Medical Specialists, incorporating guidance on course duration, microscope-to-trainee ratios, staged progression from lower-fidelity to live models, attention to the 3Rs of ethical model use, and competency-based advancement. Third, they refined the curriculum iteratively based on feedback from the pilot participant, faculty, and learners.

The finalized program is organized into five modules: Theoretical Foundations of Microsurgery, Practical Microsurgical Skills, Teaching Methodologies, Assessment and Feedback, and Continuous Professional Development. The first two modules reinforce technical knowledge and the quality of demonstrations, while the third and fourth target the pedagogical core of the course, including systematic explanation of complex procedures, real-time error recognition, and calibrated feedback. The final module emphasizes ongoing engagement with the global microsurgical community. Entry requirements are deliberately stringent: completion of the Basic Microsurgery course is mandatory, the Advanced course is strongly encouraged, and prior instructional experience is favored, so that participants enter with enough technical reserve to focus on pedagogy rather than their own task execution.

The heart of the model is a scaffolded version of the traditional surgical maxim ‘see one, do one, teach one.’ In the pilot implementation, the inaugural participant, an experienced microsurgery practitioner and educator affiliated with the Center for Surgical Technologies at KU Leuven in Belgium, progressed from observing faculty demonstrations of tissue handling, ergonomic positioning, and instrument control, to serving as a supervised teaching assistant in the Basic Microsurgery course, to coaching learners at the bench with immediate faculty backup, and finally to assuming increasing instructional autonomy. Demonstrations were performed under the operating microscope and projected onto a large monitor, allowing trainees to watch the operative field while hearing real-time explanations of technical steps and common errors.

The apprenticeship format surfaced lessons that written curricula rarely capture. The participant highlighted the importance of timing instructor intervention, phrasing corrective feedback, and balancing challenge with psychological support. Serving as a teaching assistant also exposed the heterogeneity of learner needs: some trainees benefited from repeated demonstration, while others responded better to brief corrective cues or alternative hand-positioning strategies. The distinction between performing a maneuver and explaining it clearly enough for a novice to reproduce emerged as a critical developmental step in its own right.

Evaluation, though limited by the pilot’s single-participant design, was encouraging. Six learners taught across ten sessions completed anonymous evaluations with eight Likert-style items scored from 1 to 5. The participant earned a mean item rating of 4.63 out of 5, with the highest marks for individual attention and guidance and for communication of complex ideas, both averaging 4.83. Across all 48 item responses, 97.9 percent were rated 4 or 5. Open-ended comments emphasized demonstration clarity, approachability, and responsiveness to technical errors, with one learner suggesting that even more confident delivery and live demonstration could strengthen future sessions. The participant received a Certificate of Training from Columbia University’s Department of Orthopaedic Surgery upon successful completion.

A twelve-month follow-up offered early evidence that the training transfers. The participant reported that the curriculum remained useful in her home laboratory, particularly its emphasis on active observation of learners under the microscope, use of live camera systems as a lower-stress alternative for feedback, and encouraging trainees to verbalize procedural steps to deepen understanding. She also identified real-world constraints that future iterations should address, including locally available instruments that did not always match the standard setup and institutional or cultural differences, such as more cautious practices around images involving experimental animals. Because equipment and model differences led her to teach techniques that varied modestly from the standard curriculum, she recommended that future versions incorporate a broader range of acceptable technical approaches to prepare instructors for diverse laboratory environments.

The program is supported by the laboratory’s open-access training manual, Microsurgery 101: Tips and Tricks for Microvascular and Peripheral Nerve Repair Techniques, and its accompanying video series, which detail the microvascular and peripheral nerve procedures taught in MTRL courses. The authors view curated video modules not as a replacement for expert supervision but as a tool to standardize demonstrations and reinforce technical steps between laboratory sessions, consistent with adult learning theory and active-learning principles. They caution that the study reflects a single pilot participant, descriptive analysis, and nonvalidated evaluation instruments, so claims of effectiveness remain preliminary. Future priorities include implementing the curriculum across multiple participants, developing structured instructor-assessment tools potentially leveraging artificial intelligence, and longitudinal follow-up to determine whether graduates sustainably implement microsurgical teaching at their home institutions. If those steps succeed, the researchers suggest, deliberate preparation of educators may prove as important as training individual operators in making high-quality microsurgical education consistent, safe, and accessible worldwide.

Subject of Research: A pilot Train-the-Trainer curriculum for preparing microsurgery educators at Columbia University

Article Title: Cultivating the next generation of microsurgery instructors: a pilot model for microsurgical train-the-trainer programs

Article References: Hutson, R., Abboud, J., Jao, S., Lammens, N., Warasta, A., Snediker, S., & Akelina, Y. (2026). Cultivating the next generation of microsurgery instructors: a pilot model for microsurgical train-the-trainer programs. BMC Plastic and Reconstructive Surgery, 2(1), Article 14. https://doi.org/10.1186/s44452-026-00026-8

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00026-8

Keywords: microsurgery, surgical education, train-the-trainer, educator development, microsurgical training, teaching methodologies, simulation-based training, medical education, apprenticeship model, competency-based training, reconstructive surgery, Columbia University

Previous investigations into gender gaps in surgical training have relied largely on summary-level data captured at a single moment: graduation. Those studies consistently found that female trainees finish residency with lower Accreditation Council for Graduate Medical Education (ACGME) case totals and report lower intraoperative autonomy than male colleagues. But such snapshots could not answer a critical question that has vexed educators for years—do these disparities exist from day one, or do they develop over the five-year arc of surgical apprenticeship? The new research, published in Global Surgical Education, the journal of the Association for Surgical Education, set out to trace exactly when and how these differences emerge.

The scale of the dataset is what sets the study apart. Researchers analyzed 569,761 individual ACGME case log entries generated by residents at six programs, matching them to 415 attending surgeons, of whom 141, or 34 percent, were women. Crucially, the team obtained resident and attending gender through self-reported data from the SIMPL platform, a smartphone-based surgical performance feedback system, since gender is not recorded in standard ACGME case logs. Nearly half of the residents, 234 of 473, were women. The programs themselves reflected national demographics, with female resident representation ranging from 42 to 58 percent across sites.

Each case entry captured the resident’s post-graduate year, the operative role recorded, and the identity and gender of both trainee and attending surgeon. ACGME case roles fall into distinct categories: first assistant, in which the resident helps another surgeon; surgeon junior and surgeon chief, which together constitute primary surgeon roles; and teaching assistant, in which a chief resident supervises a junior resident through an operation. These designations matter enormously. The American Board of Surgery and program clinical competency committees use case log data to judge whether residents are ready to graduate and to practice independently.

The headline finding was stark. On average, female residents logged 8.1 percent fewer total cases than male residents—1,153 versus 1,255, a statistically significant difference. Yet the more revealing pattern emerged when the researchers stratified cases by operative role and training year. There were no meaningful differences between male and female residents in how often they logged cases as primary surgeon. The divergence appeared instead in first assistant entries, and it widened dramatically with seniority. Female residents were 1.57 times more likely than male peers to log a case as first assistant in their third year of training, with an odds ratio of 1.57 and a 95 percent confidence interval of 1.14 to 2.16. By the fourth year that odds ratio climbed to 2.76, and by the fifth and final year it reached 3.72—meaning senior female residents were nearly four times as likely to record themselves in the assisting role.

The temporal pattern is what makes the finding so consequential. In the early years of residency, serving as first assistant is expected and appropriate; PGY1 residents in the dataset logged 15,047 first assistant cases, a figure that fell to just 212 among PGY5 residents as trainees assumed the surgeon’s role. But a substantial minority of residents continued logging first assistant cases deep into senior years—52 percent of PGY3 residents, 33 percent of PGY4 residents, and 14 percent of PGY5 residents did so. Among this persistent group, women were markedly overrepresented. The most frequently logged first assistant cases included laparoscopic cholecystectomy, laparoscopic appendectomy, inguinal hernia repair, ventral hernia repair, and colectomy—core general surgery procedures in which senior residents should be operating with increasing independence.

The study also examined whether the gender of the attending surgeon shaped these patterns, a question no prior case log analysis had been able to address. Overall, cases performed with female faculty were less likely to be logged as first assistant, with an odds ratio of 0.79. Yet among senior residents the association reversed: PGY4 residents operating with a female attending were 1.68 times more likely to log first assistant cases, and PGY5 residents were 2.46 times more likely. Notably, the researchers found no significant differences between gender-concordant and gender-discordant resident-attending pairings, suggesting that simple matching of trainee and faculty gender does not explain the observed trends. The authors caution that the mechanisms behind these attending-level effects—whether they reflect differences in teaching style, entrustment behavior, or documentation habits—remain outside the scope of the current data and merit dedicated investigation.

Why would female senior residents log more first assistant cases? The authors emphasize that the dataset cannot establish causation, and they lay out competing explanations that likely operate in combination. Extrinsic factors could include faculty perceptions, institutional culture, or the timing of cases within the academic year, while intrinsic factors might involve self-perception, confidence, and how residents understand the role definitions themselves. Teaching assistant and first assistant categories lack the strict criteria, such as post-graduate year level, that govern primary surgeon designations, making them more vulnerable to misinterpretation. Indeed, since primary surgeon cases showed no gender difference at all, the researchers suggest that some of the disparity may stem from inconsistent application of logging guidelines rather than unequal operative opportunity. At the same time, they are careful to note the well-documented literature on gender-based discrimination in surgical training, acknowledging that the uneven distribution of operative roles may reflect faculty bias or structural inequities that limit women’s chances to operate as lead surgeon.

The study carries important limitations that the authors confront directly. The data contain no information about case complexity beyond procedural codes, which are known to be inaccurately recorded, and the analysis excluded residents whose gender data was missing or reported as other or prefer not to answer, leaving the experiences of non-binary trainees unexamined. Race and ethnicity data were absent entirely, a significant gap for any work on equity. The sample was also confined to large university-based programs, which may limit generalizability, although the consistency of the trends with national-level data lends credibility to the findings. One resident, for example, logged an exploratory laparotomy as a teaching assistant case during the first year—a clear misclassification that illustrates the noise inherent in self-reported logs, even as subtler errors likely permeate the data.

The implications reach well beyond the operating room. As surgical education shifts toward competency-based training and Entrustable Professional Activities, understanding how different trainee subpopulations use measurement tools becomes essential to interpreting quantitative data fairly. The authors call for future research pairing ACGME case logs with faculty EPA assessments and resident self-evaluations, alongside qualitative studies of how residents actually decide which role to record. In the meantime, they offer a pragmatic recommendation: individual programs can apply the same analytical methods to their own case log data, monitoring for disparities by gender, PGY level, and even rotation site in real time. Such local surveillance, the researchers argue, could allow program leadership to identify senior residents who continue logging first assistant cases, clarify the correct application of role definitions, and address any underlying inequities before they calcify into a training record—and perhaps a career trajectory—that understates a surgeon’s true capabilities.

Subject of Research: Gender disparities in operative case logging and surgical training roles among general surgery residents

Article Title: Gender disparities among general surgery residents’ ACGME case logs develop over the course of training

Article References: Singleterry, M. D., Picart, J. K., Krumm, A., Sandhu, G., & White, E. M. (2026). Gender disparities among general surgery residents’ ACGME case logs develop over the course of training. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 169. https://doi.org/10.1007/s44186-026-00575-7

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00575-7

Keywords: general surgery, residency training, ACGME case logs, gender disparities, operative autonomy, surgical education, first assistant, attending surgeon gender, SIMPL, graduate medical education, operative experience, competency-based training

The American Board of Pediatrics recently announced a plan to alter pediatric subspecialty fellowship training, moving toward a competency-based framework that would, for neonatal-perinatal medicine, condense what has traditionally been a three-year fellowship into a shorter pathway. Proponents of such reforms point to workforce shortages, the financial strain of prolonged training, and evidence that clinical competence can be demonstrated and certified through entrustable professional activities rather than time served. The board’s stated goal, articulated in its 2026 announcement on ensuring readiness for practice, is to advance competency-based subspecialty training so that physicians enter independent practice sooner without sacrificing skill. For a field grappling with persistent recruitment challenges and rising demand for neonatal intensive care, the appeal is obvious.

Yet Kukora and her colleagues argue that this framing overlooks something fundamental: professional identity formation, often abbreviated as PIF in the medical education literature. Drawing on decades of scholarship, including the influential schematic model developed by Richard and Sylvia Cruess and colleagues at McGill University, the authors describe professional identity formation as the process through which trainees internalize the values, behaviors, and norms of medicine, gradually coming to think, feel, and act like the physicians they are training to become. This transformation does not occur through the mere accumulation of procedures or checklists. It unfolds within what educational theorists call a community of practice, an immersive social environment in which novices learn by participating alongside experienced mentors, absorbing not only explicit teaching but also the hidden curriculum of daily clinical life.

Neonatal-perinatal medicine presents a particularly demanding context for this transformation. Neonatologists care for infants at the very margins of viability, make life-and-death decisions under profound uncertainty, and navigate emotionally charged relationships with families in crisis. The ethical terrain is notoriously difficult: decisions about initiating, withholding, or withdrawing life-sustaining treatment; the interpretation of aggregate outcome statistics for individual counseling; and the negotiation of family-centered care in settings where evidence is often incomplete. The authors emphasize that the entrustable professional activities defined for neonatology, the specific tasks considered essential for independent practice, are themselves deeply rooted in professional identity formation. Competence in these activities presupposes mature moral reasoning, the capacity to experience and manage distress, and the resilience to sustain a career in an emotionally punishing environment.

The literature on moral distress in neonatology underscores why this matters. Studies by Prentice, Janvier, Gillam, and colleagues have documented high levels of moral distress among neonatal clinicians, the anguish that arises when providers know the ethically appropriate course of action but feel constrained from pursuing it. Repeated episodes of moral distress leave behind what Epstein and Hamric have described as moral residue, a cumulative erosion that contributes to the crescendo effect of escalating distress over time. Compassion fatigue, secondary traumatization, and burnout are well documented among neonatologists, and physician burnout has been linked in multiple studies to increased medical errors and worse patient outcomes. Professional identity formation, the authors argue, is one of the key mechanisms through which clinicians develop the meaning and purpose that buffer against these occupational hazards. Research by Toubassi and colleagues has explicitly linked professional identity formation to well-being, suggesting that a coherent sense of professional self is not a luxury but a protective factor.

Against this backdrop, the prospect of condensing fellowship raises a series of ethical concerns. First, there is the problem of time itself. Identity development is longitudinal and cannot be reliably compressed without consequence. Qualitative longitudinal research on how residents develop virtues suggests that character formation in medicine depends on sustained experience, reflection, and mentorship over time. A trainee who spends fewer months in the neonatal intensive care unit has fewer opportunities to witness and internalize how seasoned clinicians handle uncertainty, communicate bad news, repair errors, and honor the values of family-centered care. Second, the authors point to the discontinuity problem in medical education, a topic recently analyzed in the New England Journal of Medicine by Warm and colleagues. Shortened, fragmented training pathways risk disrupting the continuity of relationships, between trainees and mentors, and between trainees and the patients and families they follow over weeks and months, that make deep learning possible.

Third, the perspective highlights the hidden curriculum, the informal and often unspoken lessons trainees absorb from their environments. When institutions signal that training is primarily a throughput problem to be optimized, trainees may internalize a transactional view of their profession. Conversely, when programs deliberately protect time for reflection, ethics education, and relationship-building, trainees are more likely to develop the habits of moral attention that neonatal practice demands. Ethics education in neonatology, as recent work in NeoReviews by Sullivan and colleagues illustrates, increasingly integrates theory, multimodal teaching methods, and even artificial intelligence innovation, but it requires protected space within the training structure to take root. A compressed pathway that crowds out these formative experiences may produce technically competent graduates who are nonetheless underprepared for the ethical weight of their role.

The authors are careful to acknowledge the legitimate pressures motivating reform. The pediatric subspecialty workforce faces genuine shortages, and neonatal intensive care admissions in the United States have risen steadily, according to National Center for Health Statistics data covering 2016 through 2023. Burnout and workload concerns have prompted serious discussion of hours-based scheduling in neonatology, and some have argued in the Journal of Perinatology that the field should indeed move to two-year fellowships. A companion critical appraisal by Vergales and colleagues examined the American Board of Pediatrics’ proposed two-year pathway in detail, questioning whether the required competencies can realistically be achieved in the condensed timeframe. The debate is thus not between reform and stagnation, but between competing visions of what fellowship is ultimately for.

What distinguishes the Kukora paper is its insistence that the answer must be framed in ethical rather than merely operational terms. The authors argue that it is an ethical imperative for neonatal-perinatal medicine fellowship programs to nurture the evolving professional identities of their learners, because those learners will guide future innovation and progress in the field while providing ethical, family-centered, high-quality clinical care. If professional identity formation is foundational to every essential entrustable professional activity in neonatology, then any reform that undermines it risks compromising not only individual careers but the profession’s core mission. The stakes, in other words, are borne ultimately by newborns and their families, who depend on physicians trained not just to perform interventions but to deliberate wisely about when interventions serve the patient’s best interests.

The perspective closes with a call for the pediatrics community to take these risks seriously before implementing the new pathway. Rather than treating identity formation as an intangible byproduct of training, the authors suggest it should be treated as an explicit outcome to be protected and measured, alongside clinical competence and procedural skill. As the American Board of Pediatrics moves forward with competency-based subspecialty training, the challenge will be to design programs that achieve efficiency without hollowing out the human and moral development that makes a neonatologist more than a technician. The paper’s central message is stark: how the profession trains its future members will shape, for better or worse, the care that the smallest and most vulnerable patients receive for decades to come.

Subject of Research: Ethical implications of condensing neonatal-perinatal fellowship training for neonatologists' professional identity formation

Article Title: Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship

Article References: Kukora, S. K., Gray, M. M., McLean, C. K., & Krick, J. (2026). Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02899-0

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02899-0

Keywords: neonatology, professional identity formation, medical education, fellowship training, American Board of Pediatrics, moral distress, medical ethics, neonatal-perinatal medicine, competency-based training, burnout, family-centered care, Journal of Perinatology