Last reviewed: October 27, 2026
Residents are often told to “prepare for the case.” That usually means knowing the indication, anatomy, imaging, operative steps, alternatives, and major complications. All of that matters. But there is another question that can change the educational value of the operation before anyone scrubs: What, specifically, are you trying to get better at today?
A resident can read extensively and still enter the operating room with no shared understanding of what they will actually be allowed to do. An attending can intend to teach and still discover halfway through the case that the resident expected a different role. The operation then becomes educationally reactive: responsibility is negotiated while the procedure is already happening.
A short preoperative learning conversation does not guarantee autonomy. It does something more realistic: it makes the resident’s preparation, the attending’s expectations, and the patient-specific limits of the case visible before the pressure rises.
Case preparation and learning preparation are different
Clinical preparation asks: Why is this operation being done? What anatomy matters? What could go wrong? What is the operative strategy?
Learning preparation asks: Which part of this case is appropriate for me to own? Where do I still need direct coaching? What should the attending watch closely? What would meaningful progress look like by the end?
The distinction becomes more important as residency progresses. Early trainees may need broad goals: maintain exposure, identify the correct tissue plane, handle instruments efficiently, close safely. Later residents need narrower targets: lead the exposure without prompting, identify the decision point before the attending states it, perform a defined phase with indirect supervision, or explain when the planned approach should change.
If you already use the site’s 15-minute case-preparation framework, think of the learning goal as the final line of that preparation rather than another hour of studying.
Why “I want to do more” is a weak goal
Wanting more operative experience is understandable, but it gives an attending very little information. “Can I do more today?” leaves unanswered what the resident can already do, which phase they have prepared, and where supervision should change.
A stronger goal is observable. For example: “I have done the exposure several times; today I would like to lead it and have you step in if I lose the plane.” Or: “My weak point in the last case was orientation before the critical step. I want to verbalize the anatomy and plan before proceeding.”
This is not a script that guarantees the resident that portion of the operation. Patient factors, case complexity, time pressure, unexpected anatomy, resident performance, and the attending’s judgment all matter. The point is alignment, not entitlement.
The evidence supports making expectations explicit
This idea is increasingly consistent with the formal direction of surgical training. The American Board of Surgery (ABS) now uses 18 core Entrustable Professional Activities (EPAs) in U.S. general surgery. The ABS describes EPAs as workplace-based, feedback-oriented assessments intended to connect competency decisions to the clinical work residents already perform. In 2028, residents applying to the General Surgery Qualifying Examination will begin submitting an EPA assessment profile; requirements become more structured in 2029, while further standard setting begins in 2027.
That does not mean every operation should become an assessment exercise. It does mean that surgical education is moving toward a clearer question than “What PGY are you?”: What part of this professional activity can this resident be trusted to perform, under what level of supervision, in this context?
Research on operative education also suggests that residents and attendings do not always perceive autonomy in the same way. In a multicenter study involving 8,681 operative observations, trainee and attending autonomy ratings differed in 40% of cases, although large disagreements were uncommon. A national needs assessment found that most respondents believed discussing autonomy before an operation could improve resident autonomy, yet structured preoperative briefing was not routine.
More recently, a 2026 study of the Goals, Autonomy, Preparation, and Strategy (GAPS) framework reported improved briefing frequency, discussion of resident learning objectives and autonomy, and ratings of intraoperative teaching quality after implementation, without a significant increase in measured cognitive load. These studies do not prove that a brief conversation automatically makes someone a better surgeon. They do support a practical conclusion: expectations that remain unspoken are harder to align.
A useful pre-op conversation can take less than a minute
The resident does not need to deliver a speech. The conversation can answer four questions:
- Goal: What am I trying to improve in this case?
- Role: Which phase might I reasonably lead?
- Supervision: Where does the attending want to be more or less hands-on?
- Strategy: What patient- or case-specific issue could change that plan?
For a familiar case, that may be enough. For a complex or unfamiliar operation, the conversation may appropriately be longer and include imaging, bailout strategies, or explicit thresholds for the attending to take over.
Choose one target, not seven
The temptation after a difficult operation is to arrive at the next one trying to fix everything. That usually produces a vague goal such as “be smoother.” A more useful approach is to identify the bottleneck.
Was the problem knowledge? Exposure? Instrument handling? Tissue respect? Orientation? Anticipation? Communication? Pace? Knowing when to stop? Asking for help too late?
Pick the item that most limited the previous performance and make it visible in the next appropriate case. This turns feedback into a testable change. It also connects naturally with asking for useful feedback: feedback becomes easier to give when the observer knows what the resident is deliberately working on.
The attending’s answer is part of the education
Sometimes the response will be, “Yes, lead that portion.” Sometimes it will be, “Not today.” The second answer can still teach something if the reason is clear.
Perhaps the anatomy is unusually difficult. Perhaps the attending has not worked with the resident enough to judge their current level. Perhaps the case is time-sensitive. Perhaps a particular step has little margin for recovery. Perhaps the resident’s preparation does not yet support the requested role.
Those are different problems. “No” because of patient-specific risk should not be interpreted as “you are not progressing.” “No” because the attending has never seen you perform the prerequisite skill suggests a different next step: create an opportunity for them to observe it. “No” because preparation is incomplete is actionable immediately.
This is one reason operative autonomy is better understood as earned trust than as a reward for seniority. The site’s guide to how residents actually earn operative autonomy explores that progression in more detail.
During the operation, the goal should change how you work
A pre-op goal is useless if it disappears at incision. If the target is anatomical orientation, pause before the key step and state what you see. If the target is leading the exposure, actively direct the next move rather than waiting for instructions. If the target is judgment, explain what finding would make you change course. If the target is technical economy, notice unnecessary movements rather than merely trying to move faster.
The goal should not make the resident rigid. Operations change. A learning objective is subordinate to safe patient care, and the most educational moment may become understanding why the original plan no longer applies.
Close the loop after the case
The best post-op question is usually not “How did I do?” It is narrower: “I was working on maintaining the plane during that portion. Where did you feel I lost it?” Or: “We agreed I would lead the exposure. What made you step in when you did?”
A short debrief can produce one of three useful outcomes: the skill was good enough to increase responsibility next time; the same skill needs another repetition with similar supervision; or a different limiting skill has become visible. All three are progress because the next case now has a clearer starting point.
For skills that need repetition away from the patient, the next step may be deliberate practice rather than waiting for another operation. See how residents can use the skills lab deliberately rather than simply accumulating repetitions.
A simple resident habit: goal → case → debrief → next goal
The operating room provides enormous amounts of experience, but experience alone is not automatically deliberate learning. A resident who enters each case with one defined target, performs with that target in mind, and asks one specific question afterward creates a small feedback loop inside normal clinical work.
You do not need a complicated spreadsheet. A private learning log can be one line: case — target — what changed — next target. Over several weeks, patterns become visible. The same weakness appearing repeatedly deserves focused work. A goal that becomes reliably easy may be ready for greater independence.
That is also closer to the direction competency-based surgical education is taking. The ABS explicitly describes EPAs as frequent, workplace-based assessment linked to everyday patient care. The formal framework is national; the useful resident habit is much smaller: know what you are trying to improve before the case begins.
The point is not to negotiate every operation
Surgical training cannot be reduced to residents requesting portions of cases. The attending remains responsible for patient safety and has information the trainee may not have. Some cases are poor teaching opportunities for a particular skill. Some days the educational plan will be overtaken by clinical reality.
But there is a large difference between accepting appropriate supervision and entering every operation with unspoken expectations. A specific learning goal makes the resident an active participant in their development. A brief conversation makes it easier for the attending to calibrate teaching. A specific debrief makes the next operation more useful than the last.
The incision is not where operative learning starts. Often, it starts in the minute before it.
Sources and Further Reading
- American Board of Surgery. EPAs for General Surgery. Current implementation requirements accessed October 27, 2026.
- American Board of Surgery. General Surgery Training Requirements. Accessed October 27, 2026.
- Cooney CM, et al. Preoperative Briefings and Postoperative Debriefings to Increase Resident Operative Autonomy and Performance. Journal of Surgical Education.
- Sandhu G, et al. Beyond the Surgical Time-Out: A National Needs Assessment of Preoperative Communication in US General Surgery Residency Programs. Journal of Surgical Education.
- George BC, et al. Mind the Gap: The Autonomy Perception Gap in the Operating Room by Surgical Residents and Faculty. Annals of Surgery.
- Bridging GAPS in Perioperative Education: Implementation of the Goals, Autonomy, Preparation, and Strategy Framework. 2026.
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