Electronic Thesis and Dissertation Repository


Doctor of Philosophy


Health and Rehabilitation Sciences


Lorelei Lingard

2nd Supervisor

Sayra Cristancho

Joint Supervisor


Variations in practice and procedure permeate clinical work. While clinical research routinely investigates the consequences of these variations for clinical outcomes, we have little understanding of their implications for education. The current policy environment in medical education makes developing a new understanding of the role of variations in medical education especially important. Current policy reforms in the assessment of learners draw on the notion of competence to suggest that medical education should focus on the performance of learners in the workplace. The current turn toward workplace-based assessment positions the observations of faculty into key functions in these assessment frameworks; therefore, knowing what shapes observations in workplace-based assessment is crucial. This dissertation uses grounded theory to explore how interaction between surgeons and senior surgical residents around procedural variations shapes teaching, learning, and assessment in the operating room. The findings of the research suggest that the culture of the surgical workplace leads surgeons to engage in complex social processes in interpreting and negotiating procedural variations. A surgical culture based on autonomy and individuality leads residents to tacitly seek out thresholds of principle and preference for each surgeon they work with. Surgeons endorse residents’ tacit work as a means of learning to adapt to the ambiguity and complexity of surgical practice. The tacit thresholding work of residents may be so embedded in surgical culture that it plays an important role in determining how surgeons entrust residents intraoperatively. Workplace-based assessment could potentially utilize these intraoperative situated assessments made by surgeons. Emerging approaches to assessment suggest that attending to intuitive entrustment decisions made during everyday workflow may allow competency-based medical education to develop workplace-based assessments that make productive use of the subjectivity inherent to observations made by experts in the workplace.