Teaching safer surgery: developing clinical judgment in postgraduate training

Moving between the roles of teacher and learner provides a useful perspective on what we should make explicit in training: our reasoning, our expectations and the boundaries of the responsibility we ask trainees to take. My work combines postgraduate orthopedic teaching and spine practice. My AO Spine fellowship at the Royal Orthopaedic Hospital in Birmingham in 2026 also placed me in the learner's role. 

A six step approach for new faculty

The following six suggestions offer a practical approach for new and aspiring faculty. They can also help trainees participate more actively in their own learning. The teaching questions and examples are illustrative; each educator will need to adapt them to the patient, learner, team and local supervision arrangements. These six points will be explained in more detail below:

1. Define clinical judgment as a training goal
2. Make clinical reasoning visible
3. Match responsibility to demonstrated competence
4. Turn feedback into the next learning step
5. Teach the thoughtful use of new technology
6. Create a culture where trainees can speak up

Define clinical judgment as a training goal

Clinical judgment becomes easier to teach when we try to describe what it looks like. Before discussing a technique, I would ask a trainee to identify the patient's main concern, explain how the clinical findings support the working diagnosis and compare the benefits, risks and limitations of reasonable treatment options. The discussion should include the option of continuing nonoperative care when appropriate, as well as the limitations of the available evidence.

Consider an elective lumbar case discussion as an example. A useful starting point is to ask what the proposed intervention is intended to improve and how that improvement would matter to the patient. The trainee can then explain which findings support the plan, where symptoms, examination and imaging do not agree and what further information might change the decision. This keeps the patient's goals visible throughout the conversation.

Uncertainty deserves an explicit place in this process. Asking a trainee to name one unresolved question can be more revealing than asking whether they understand the case. The educator should welcome an answer that acknowledges uncertainty and explains what needs further discussion. Knowing when to seek help is itself a component of judgment.

A practical learning goal might therefore be: by the end of this placement, the trainee can present a patient-centered plan, justify it against alternatives and identify when to reconsider the plan or seek senior input. That goal gives both teacher and learner something observable to discuss.

Make clinical reasoning visible

Experienced surgeons often compress a complex assessment into a short recommendation. For someone learning, the reasoning that connects the findings to that recommendation needs to be explained. A brief explanation of why one feature matters, or why an apparently attractive option is unsuitable, can make a case discussion much more useful.

One approach is to let the trainee present a plan before offering the senior view. Ask what evidence supports it, what alternatives were considered and what finding would cause the trainee to change course. The five-step microskills model described by Neher and colleagues offers a useful starting point for brief clinical teaching: explore the learner's judgment, probe its basis and give focused teaching and feedback.[¹] Faculty can adapt the framework to the time available and the learning need.

The educator can then explain their own reasoning with the same openness. If two options are reasonable, describe the trade-offs and the role of patient preference. If an initial impression changes after reviewing the examination or imaging, say what changed it. This gives the trainee access to the process of revising a decision.

The setting is of importance. Detailed questioning is most useful when there is time to listen and when the trainee can answer without being embarrassed in front of a patient or a crowded team. A short discussion afterward may allow a more candid exchange. An immediate safety concern, however, needs attention at once.

Match responsibility to demonstrated competence

A trainee's level of responsibility should be clear before a clinical task begins. What will they do? Which parts will be directly supervised? What findings or difficulties should prompt them to pause and call for help? These questions turn a general instruction to participate into an understandable agreement.

The idea of entrustable professional activities connects competence with the work a learner may be trusted to undertake at a specified level of supervision.[²] For spine educators, the useful principle is to make that trust specific. A learner may be ready to assess a familiar presentation or undertake a defined part of a procedure with supervision, while needing closer guidance in a different clinical situation.

Progression should draw on observed performance across encounters, including preparation, technical performance, communication and recognition of limits. A training year or a case count provides context, but the educator still needs to consider the demands of the current patient and task. An unfamiliar procedure, difficult anatomy or a changing clinical situation may call for closer supervision.

Before a supervised task, agree on the points at which the supervisor should take over and how the trainee should signal concern. Afterward, discuss whether the level of responsibility was appropriate and what would support the next step. This makes increased participation a shared educational decision. It also helps the learner understand that requesting senior input is compatible with developing independence.

Turn feedback into the next learning step

Feedback is most useful when a learner can act on it. General praise or a long list of weaknesses can leave the learner unsure what to repeat or change. A more focused conversation can begin with one task that was observed, the learner's own assessment and one change to try next time.
For example, after a case presentation, an educator might explain that the trainee described the imaging clearly but did not connect the proposed treatment to the patient's main goal. The next learning task could be to state that connection explicitly in the following presentation. The observation is specific, and improvement can be revisited.

The R2C2 feedback model emphasizes the relationship, the recipient's reaction, discussion of the content and coaching for change.[³] Its value here is a reminder that feedback involves a conversation. Before prescribing a solution, ask what the trainee found difficult and whether they understood the task in the same way. A useful plan should make sense to the person expected to carry it out.

A short record can maintain continuity: the task observed, one effective behavior and one agreed next step. At the next suitable encounter, return to that goal. Faculty working with the same trainee can share these observations through the program's usual processes. The aim is a connected sequence of learning opportunities, supported by brief observations that faculty can realistically record and revisit.

Teach the thoughtful use of new technology

Endoscopy, navigation and robotics create important educational questions. What must a learner understand about the technique or system, its learning curve and its limitations? How will competence be assessed? What should happen when the technology behaves unexpectedly or its information does not fit the clinical situation? These questions should be part of the teaching plan from the outset.

I would organize the discussion around preparation, verification and response to difficulty. Preparation includes training appropriate to the technique or system, an understanding of its limitations and a clear plan for supervision. Verification means explaining how the team checks information against anatomy and the other evidence available. Response to difficulty includes knowing when to pause, involve the supervising surgeon and reconsider the plan before proceeding.

Rehearsal can help create space for learning before patient care. A randomized study of virtual-reality training demonstrated improved operating-room performance in laparoscopic cholecystectomy.[⁴] This illustrates the potential for simulation learning to transfer to operative practice; it does not establish the effectiveness of a particular spine training method. That requires assessment in its own setting. Rehearsal should have a defined objective and feedback, whether it uses a simulator, a model or a structured team discussion.

The clinical conversation must remain central as technical familiarity grows. A trainee should still be able to explain patient selection, the intended benefit, the risks and the alternatives. Teaching a new system also gives faculty an opportunity to model learning: identify what requires further training, seek appropriate supervision and review how the whole team will work together.

Create a culture where trainees can speak up

An invitation to ask questions is only a beginning. Trainees also need to see how questions are received when the service is busy or the senior clinician is under pressure. A dismissive response to one request for help may discourage the next concern from being raised promptly.

Research on supervised clinical training has shown that concerns about professional credibility can influence help-seeking.[⁵] An educator can address that concern by making expectations explicit: early discussion of uncertainty is welcome, and identifying a limit is a useful professional behavior. When a trainee raises a concern, acknowledge it, establish what needs attention and explain the next step.

This is also a team issue. Observational research in operating rooms has documented communication failures involving timing, content, purpose and audience.[⁶] A concern needs to reach someone who can act on it, and the person raising it needs to know that it has been heard. Teaching should therefore include nurses and other colleagues in the communication plan, with agreed ways to raise concerns and confirm that they have been understood.

Complication discussions offer another opportunity to model this approach. Faculty can examine reasoning, communication and system factors respectfully, while retaining accountability for decisions. The discussion should end with what the team will do differently in a comparable situation and how that change will be followed up. Trainees benefit from seeing senior clinicians examine their own decisions with the same care expected of learners.

A small routine to carry into the next case

A teaching routine can begin with three short conversations. Before the case, agree on the clinical reasoning, the learner's role, and one learning goal. During the task, maintain supervision appropriate to the evolving situation and make important decisions explicit when circumstances allow. Afterward, ask the learner to reflect, share one specific observation and agree on a next step.

The routine can be adapted to an outpatient discussion, an operating-room list, a ward review or a course-based exercise. Its value lies in returning attention to the same essentials: 

1. a reasoned plan
2. responsibility matched to competence
3. permission to ask for help

For new faculty, these are practical teaching behaviors to develop alongside clinical expertise. For trainees, they make expectations clearer and progress easier to discuss. The aim is to develop surgeons who can explain their decisions, recognize their limits and seek help in time.

Acknowledgments: I thank my postgraduate students, whose questions, case discussions and learning experiences continually deepen my understanding of teaching and provide the firsthand experience that informs this article.