Why you might feel less ready than you think you should, and why that isn’t a verdict on you. A message for surgical residents by author Danny Goel, a Clinical Professor in the Department of Orthopaedics at the University of British Columbia, where he trains orthopaedic surgery residents.
If you’ve ever finished a case feeling less sure of yourself than you think you’re supposed to feel at your level, or watched an attending quietly take over the hardest part of a case and wondered what that said about you, you are not imagining it, and it is not a reflection of your effort or your ability.
Ask any programme director an honest question in private: are residents graduating as ready for independent practice as they were ten or fifteen years ago? The honest answer is rarely a confident yes. That’s not because you are working less hard than the residents who came before you, and it’s not because your faculty are teaching worse. It’s because the ground underneath residency training has been shifting for two decades, quietly and almost entirely outside anyone’s individual control, resident or attending.
This isn’t a paper about what’s wrong with you. It’s about what’s actually changed, why you might feel it even without being able to name it, and why it’s worth taking seriously, because whatever gap exists when you finish training is the one you carry with you into independent practice. You deserve to know that plainly, not just be reassured.
You’re not getting fewer reps because you’re not trying hard enough
The instinct, for anyone struggling with this, is to treat it as a personal problem: work harder, ask for more time in the OR, read more at night. But the number of real, independent operative reps available to any resident right now has been shrinking from several directions at once, and none of them have anything to do with how capable or how dedicated you are.
• Duty-hour restrictions compressed total clinical hours starting in 2003, and they’ve tightened since. That’s fewer total hours, by design, not a schedule your program chose.
• The service side of those hours, call coverage, rounding, ED consults, hasn’t shrunk to match, and it’s actually grown. So when total hours get cut, the reduction falls almost entirely on OR and educational time, not on the obligations that don’t flex.
• Litigation caution makes attendings and hospitals more careful about handing over autonomy than they used to be. That’s not about trust in you personally, it’s a system-wide shift in risk tolerance.
• New implant and device systems are entering the market faster than ever, and attendings are often still climbing that same learning curve themselves, which leaves them less bandwidth to teach you on instrumentation they’re still learning too.
• Reimbursement per case has dropped sharply in real terms — Medicare physician payment is down roughly a third since 2001 after inflation, and the 2026 fee schedule cuts work RVUs on about 9,000 procedural codes, including orthopaedics. Departments still set the same productivity targets regardless. When a case is worth less and the volume target doesn’t move, the fastest way for a faculty member to hit their number is to do the case themselves instead of teaching it through. If a case has felt rushed lately, this is very likely why, and it isn’t something your attending is choosing out of indifference to you.
• Sub-specialization has narrowed how many different kinds of cases any one resident sees, even in the OR time you do get.
• The easiest, highest-repetition cases, the ones that used to build basic comfort and speed early on, are increasingly moving to ambulatory surgery centers built around throughput. Residents are often not credentialed to operate there at all.
None of this is about your effort. It’s a set of forces compounding on top of each other, and it would be showing up the same way no matter who was standing in your shoes.
You may technically have more unstructured time than residents did a decade ago. If that time isn’t converting into extra self-directed practice, that isn’t a discipline problem, it’s a completely rational choice to protect the rest you need to function, and no one should make you feel guilty for choosing sleep over solo practice at 11pm. Anything that quietly assumes you’ll find hours you don’t actually have is a plan that was never going to work, for you or for anyone in your position.
It’s also worth knowing this runs both ways. Your attendings aren’t sitting on some hidden reserve of extra teaching time either. Research and publication expectations, promotion requirements, society and committee work, their own certification and CME requirements, and their own catching-up on new techniques are all competing for the same hours a program might hope they’d spend on extra mentorship. This isn’t a resident problem, and it isn’t a faculty problem. It’s the same structural squeeze, hitting both sides of the same relationship.
The way you’re being taught doesn’t match how learning actually works, and that’s not on you either
Beyond the number of reps, it’s worth asking whether the teaching you do get is even structured the way people actually learn. On several fronts, it isn’t, and this has been well understood in learning science for a long time.
Take the forgetting curve, described by Hermann Ebbinghaus more than a century ago: newly learned material decays fast without reinforcement, with the steepest drop in the first hours and days after you first see it. If you sat through a lecture or a cadaver lab on a procedure in January and can’t quite recall the specific pitfalls by the time you actually scrub in on something similar in April, that’s not a memory problem you have — that’s the forgetting curve doing exactly what it’s been documented to do for over a hundred years. A single lecture, disconnected from when you’ll actually use it, is built almost in spite of how memory works, not in support of it.
The spacing effect makes this worse. Material sticks far better when it’s spread across intervals than when it’s delivered all at once, but rotations and boot camps run almost the opposite way: intense weeks in one subspecialty, then nothing on it again for the better part of a year, with no structured reinforcement in between. Board prep follows the same pattern — most people intensify studying only in the weeks before the exam, which is exactly the kind of cramming the research says produces weaker long-term retention. If you’ve ever felt like you ‘knew it cold’ right before a rotation ended and then felt rusty months later, that’s not you forgetting something you should have retained. That’s the predictable result of a training calendar that isn’t built around spacing.
There’s also a concept called the zone of proximal development, the space between what you can already do alone and what you can only do with guided support, which is where real skill-building actually happens. The current model rarely calibrates to you individually. How much of a case you’re allowed to do often gets decided more by OR scheduling and a blanket PGY-year rule than by an honest read of where you personally are on that specific skill. That cuts both ways: sometimes you get handed something ahead of where you’re ready, with no real scaffolding because your attending doesn’t have the bandwidth to provide it in the moment, and sometimes you’re held back from something you’ve clearly already mastered simply because “PGY-2s don’t do that part yet” is a blanket rule, not a judgment about you specifically. Either way, if it’s ever felt mismatched to your actual level, it probably was, and that’s a scheduling artifact, not a verdict on your ability.
One more piece of this is worth naming plainly: residency is still taught largely as one-size-fits-all — one lecture series, one set of PGY-year expectations, applied to a room full of people who don’t actually learn at the same pace or start from the same strengths. A lecture built for the “average” resident is, almost by definition, a little wrong for almost everyone in the room: too slow for someone who already has a head start, too fast for someone seeing it for the first time. If a topic has ever felt oddly easy or oddly overwhelming compared to how your peers seemed to experience it, that’s the model doing what group teaching does, not a signal about where you stand.
The missing warm-up
No serious athlete walks onto the court cold. A basketball player shoots free throws before tip-off. A concert violinist runs scales backstage before walking on stage. Surgical training, almost by accident, never fully adopted that same basic premise, and it’s worth knowing that the absence of a deliberate warm-up before a case isn’t a habit you’re missing, it’s a habit the whole field never built in.
Given how limited real operative reps already are, a few focused minutes right before scrubbing in, walking through the steps in order, anticipating where things typically go wrong, could meaningfully change how much you actually get out of a single case, without needing extra OR time or anything your program doesn’t already have. It’s also a direct, practical way to work with the forgetting curve instead of against it: reviewing the relevant steps minutes before a case draws on that knowledge while it’s freshest, instead of weeks after a lecture hall first introduced it. If this isn’t something you’re already doing, that’s not a gap in you, it’s a gap in what anyone ever told you to try.
Here’s the uncomfortable part, and it’s worth knowing even though it’s uncomfortable: How you’re measured is quietly broken
This section is the one that matters most to say plainly, because it affects how much you should trust the signals you’re currently getting about your own readiness.
Faculty evaluation forms are supposed to measure specific competencies, but research shows evaluators tend to rate residents on a global impression, “good resident” or not, rather than genuinely distinguishing between the specific skills the form claims to measure. There’s a well-documented reason for this, and it isn’t carelessness on your attending’s part: cognitive psychologists call it the fluency illusion, the tendency to read someone’s ease and confidence in the moment as evidence of their underlying competence, even when the two aren’t actually related. If you’ve ever felt like you were judged more on how smoothly you presented a case than on whether your actual reasoning was sound, you weren’t imagining that. It’s a real, well-studied bias that affects nearly every evaluator, and it happens to be exactly the bias a system built on subjective impression is most exposed to.
Case logs carry a similar issue, in a way that’s easy to miss because a number on a page looks like hard evidence. Attending supervision tends to concentrate on the hardest, highest-risk part of a case, where your attending is more likely to take over or closely guide every movement, and open up more on the lower-stakes steps like exposure and closure. The case still gets logged as performed either way. So it’s entirely possible to satisfy every numeric case requirement in your file while having built genuine independent competence mainly in the least consequential parts of each one, and that isn’t something you did wrong, it’s just how supervision naturally allocates itself around risk.
The most important thing to say directly, because no one always says it out loud: OITE and written board scores correlate well with other knowledge exams, which makes sense, they’re all measuring recall of the same kind of information, but there is no published evidence connecting those scores to actual operative skill or patient outcomes. What the evidence does show is narrower: people who fail board exams have measurably higher malpractice rates than those who pass, which suggests these exams work reasonably well as a floor, catching people with serious underlying gaps. That is a very different claim from saying a high score tells you anything about your surgical skill above that floor. If you score well on the OITE, you have real evidence your medical knowledge is strong. You don’t automatically have evidence that your technical skill or operative judgment is equally strong, and if no one ever says that plainly, it’s completely reasonable to assume the two must track together. That assumption isn’t just imprecise, it can be genuinely unsafe heading into independent practice, not because you did anything wrong, but because the exam was never designed to measure that in the first place. This isn’t meant to shake your confidence in what you do know. It’s meant to make sure your confidence is resting on the right evidence.
The field is starting to catch up to this. The American Board of Orthopaedic Surgery’s Knowledge, Skills, and Behaviour program, required starting with residents applying for Part I in 2026, adds structured surgical-skills assessment and an annual 360-degree behaviour review on top of the written exam. That’s a real, meaningful step, and it’s worth knowing it exists precisely because it’s the field formally acknowledging that knowledge, skill, and behaviour are three separate things, and a knowledge exam was never going to stand in for all three.
Here’s why this matters beyond the exam itself: supervision in surgical training doesn’t taper off gradually, it disappears almost overnight the day independent practice starts. If you’ve ever privately sensed you’re less prepared than your scores suggest, even without being able to put your finger on why, the anxiety that produces at exactly the moment supervision ends is a well-documented, real feature of the transition to independent practice. It is not a sign that you don’t belong, and it’s not a personal failing. It’s a predictable consequence of a measurement system that was never built to catch this gap, and it deserves to be named for you clearly instead of something you carry quietly on your own.
The pressure you feel to look prepared isn’t vanity, it’s smart, and it’s worth knowing why
It would be easy to read all of this and conclude that residents simply won’t put in extra effort on their own time. That’s not true, it’s just aimed at a different target than most training tools assume. Like anyone, you’re constantly managing how you’re perceived by the people whose opinion actually shapes your future, and for a resident, almost no one’s opinion matters more day to day than the attending across the table or the OR table from you. Rounds, case presentations, and being questioned mid-case aren’t just educational moments, they’re where trust and autonomy are actually being won or lost, in real time, in front of the person deciding how much rope you get next.
This is exactly why a resident who won’t crack a textbook on a random day off will prepare intensely for a case they know they’ll be questioned on, or a conference they’re presenting at, or rounds in front of a new attending. Your motivation was never missing. It’s just been aimed at the moments that felt highest-stakes, and honestly, that’s not a character flaw, it’s a completely reasonable instinct: to not look unprepared in front of the people who decide what comes next for you.
What this actually means for you
None of this is a verdict on your ability or your work ethic. If something has felt off compared to what training is supposed to produce, you’re picking up on something real, documented, and largely outside your control, not a sign that you personally aren’t cutting it.
It’s still worth taking seriously, though, because residency doesn’t repeat. Whatever readiness you have when you finish is what you carry into independent practice, and the anxiety that can show up at that transition is real and well documented, not evidence that you don’t belong.
A few things genuinely are within your control, and none of them require more hours than you have: warming up deliberately in the minutes before a case instead of walking in cold, being honest with yourself about the difference between testing well and being ready to operate independently, and asking directly for feedback that goes beyond a general impression when you can.
The bigger structural pieces, duty hours, reimbursement pressure, how programs measure competency, teaching that’s personalized rather than one-size-fits-all, were never yours to fix alone, and they were never supposed to be. That responsibility sits with your program directors, your faculty, and the systems currently being built to close this gap, and plenty of people, including the ones training you right now, take it seriously.
You’re not behind. You’re training inside a system that changed faster than the tools meant to support it did. Naming that clearly, instead of leaving it as a quiet feeling nobody puts into words, is the least any of us owes you.
Article and image are author’s own. Image: Resident using PrecisionOS
