Attending Surgeons’ Perspectives on Promoting Flourishing During Residency

Abstract

Through semi-structured interviews with attending surgeons, this exploratory qualitative study examined ways in which eleven surgeons create conditions for residents to flourish in the clinical learning environment. We conducted interviews with a purposeful sample of eleven surgical faculty from across the United States. The transcripts were deductively coded using VanderWeele’s (2017) flourishing framework, which includes character and virtue, close social relationships, meaning and purpose, and life satisfaction. Through open coding and thematic analysis, we identified three interrelated themes: (1) acting to promote good through mattering, (2) deriving satisfaction from individualizing teaching, and (3) affirming the worth of residents as humans.

1. Introduction

Teaching in the clinical learning environment (CLE) is under national scrutiny for historically perpetuating a culture of shame and fear that harms resident learning, retention, and psychological well-being [1,2,3,4]. In this training setting, clinical teachers play a vital role in developing residents and shaping the environment and culture in which they are trained, which in turn influence resident flourishing [5,6].

A primary way teachers shape the CLE is by individualizing their teaching. Researchers found that residents value clear communication and mutual respect [7,8,9]. Residents emphasize the importance of educators who assess their needs, clearly communicate expectations, and adjust pacing based on learner readiness [10]. Skilled surgical educators calibrate their teaching to each learner’s level rather than using a one-size-fits-all approach [7].

To understand how these teaching values contribute to broader outcomes, we turned to the concept of “flourishing”. VanderWeele (2017), through the Harvard Flourishing Project, distinguishes between well-being and flourishing, emphasizing that specific contextual elements—such as values, relationships, and meaning—are essential for flourishing [11]. Flourishing also differs from the traditional notion of well-being in that it emphasizes “a more complete fulfillment” [12]. Tyler VanderWeele’s framework for flourishing is a multidimensional, evidence-based approach. Five key domains are essential for a flourishing life: happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, and close social relationships. This expansive view moves beyond traditional economic or health metrics of well-being. Virtue is a significant aspect of flourishing, and the emphasis of living character virtues such as gratitude, humanity, and humility is another way in which flourishing differs from traditional views of well-being [11]. The flourishing framework acknowledges the importance of both individual agency and structural conditions, advocating for public policy and institutional practices that support human flourishing across diverse populations [12].

The concept of flourishing varies between Eastern and Western philosophy (see

Table 1. Eastern and Western philosophy.

Western Philosophy	Eastern Philosophy
Aristotle—Cultivating character strengths and living purposefully in concert with virtues leads to flourishing.	Buddhism—Only by suffering and learning to face and reduce suffering, can one-reach sukha (well-being). Sukha involves achieving Nirvana (inner peace) through living ethically, achieving wisdom, and mindfulness.
Seligman—Happiness leads to flourishing. Flourishing is achieved through personal strength and virtue, achieved through positive emotion, engagement, and meaning.	Taoism—Flourishing can be achieved by aligning with the Dao (the Way) and embracing Wu wei (effortless action).
VanderWeele—Need to understand conditions and responses to suffering that can lead to development and growth toward flourishing. Contexts in which a person lives and works affect flourishing.	Confucianism—Flourishing involves living with virtue and duty.
Emphasis is on “relative attainment” of the ideal of flourishing, with the environment being conducive to growth as a critical component of flourishing.	Emphasis is on achieving harmony, achieving moral excellence through empathy, compassion, and care in relationships.

for an overview of the Eastern and Western philosophies of flourishing) [13]. In a recent study, VanderWeele conducted a global study on flourishing in 22 countries [14]. The results indicated that flourishing was influenced by age, with participants aged 18–49 reporting the lowest flourishing scores. These results substantiate the need to help resident physicians, who are primarily in this age group, through teaching aimed at learner flourishing.

Flourishing includes four domains that are highly relevant to the CLE: character and virtue, close relationships, meaning and purpose, and life satisfaction. VanderWeele et al. argue that it is important to engage in qualitative work to understand the perspectives of what flourishing looks like in specific professional settings, extending from empirical quantitative research conducted to date [15]. To that end, we asked how attending surgeons who intentionally promote learner flourishing describe effective teaching.

2. Materials and Methods

2.1. Study Design

This study focused on the role of attending surgeons as educators through interviews with practicing surgeons. This exploratory study was designed using interpretive description, a qualitative research approach that enables context-specific examples to be drawn from a purposeful sample. This approach draws on perceptions, feelings, and beliefs associated with surgeon experience and allows for the identification of patterns—such as character virtues—that emerge in surgical teaching [16]. We used criterion-based purposeful sampling to recruit attending surgeons who had prior exposure to the concept of learner flourishing. Eligible participants were identified via their involvement in Kern National Network for Flourishing in Medicine-sponsored workshops, webinars, or collaborative projects focused on flourishing in medicine. The participants were not compensated [17]. This study was deemed IRB Exempt #00010249.

2.2. Participants

Fifteen attending surgeons were invited to participate in an interview about their teaching of residents. Twelve responded to the invite, one did not respond to further messages to schedule an interview, and eleven were interviewed. Informed consent was obtained prior to each interview. Each of the attendings worked with physician residents daily. There were 6 female and 5 male surgeons from 7 different institutions, with a median of 14 years of experience. Small, well-selected samples can provide rich, meaningful data when participants have experiential depth relevant to the topic under study [18]. Such exploratory qualitative work is especially needed in surgical education, where understanding how individuals make meaning of their experiences in the CLE remains underexplored [19].

2.3. Interviews

Because of our goal to explore how surgeons teach toward flourishing, we drew on the Kern National Network’s Framework for Flourishing and the Harvard Flourishing framework to guide the interviews [11]. We design open-ended questions aimed at eliciting specific examples of character, relationships, purpose, and life satisfaction being promoted in clinical teaching. The structured interview protocol was piloted with two surgeons and revised based on their feedback for clarity in questioning and probes for understanding. Each interview lasted approximately 40 min. The interviews were recorded and transcribed verbatim by REV encrypted transcription service. Each transcript was reviewed for accuracy and de-identified (see Appendix A—Interview Guide).

2.4. Data Analysis

The data analysis initially followed a deductive approach to ensure rigor. We employed three coders to achieve investigator triangulation. The first phase involved open coding, conducted independently by the three researchers. We began by identifying themes based on four elements of VanderWeele’s flourishing framework, including character and virtue, close social relationships, meaning and purpose, and life satisfaction (See

Table 2. Framework for initial coding.

Framework for Initial Coding	VanderWeele’s Definition—Flourishing
Character and Virtue	Acting to promote good living character virtues including prudence, justice, courage, and temperance.
Meaning and purpose Close social relationships	Having a strong sense of purpose, accompanied by finding meaning at work and feeling valued for that work. Feeling a sense of belonging and value, with positive relationships that foster growth.
Life satisfaction	Overall satisfaction with personal and professional life, including a sense of optimism and self-acceptance.

). We did not analyze physical and mental health as a separate theme. Instead, we integrated this aspect into our analysis of how the attendings described the teacher–learner relationship. Following this, the research team engaged in analytic discussions focused on each participant. This process allowed for themes to emerge inductively from specific contextual examples provided by the surgeons. These examples illustrated what motivated their teaching and how they implemented approaches to foster flourishing in their educational practices. Thus, our analysis enhanced VanderWeele’s framework by integrating concrete examples from clinical education.

Our research question was: how do attending surgeons who intentionally teach toward learner flourishing describe effective teaching? With our research question in mind, through analytic memos and group discussion, we then developed three themes related to caring for an individual learner with the aim of flourishing [20].

3. Results

Virtue: Acting to Promote Good Through Mattering

Mattering encompasses both feeling valued and believing one is contributing value to an organization [21,22,23]. For residents, it also involves being seen and appreciated as a whole person, not simply as a trainee.

Helping trainees know they matter means being in tune with how residents process the high-stress rigors of medical training [24]. As Surgeon E explained:

One week there was a lot of really horrible trauma on our service, including child abuse, a patient who had been shot, and a patient who did not survive. A fourth-year resident was exposed to all of it. He looked beat up over all of this, I could just sense it in him. So, I let him know, ‘I’ve been here before, and I recognize it’s been a tough couple of days.’ We told him to take a break from clinic and go spend a little time away.

Helping a trainee feel they matter means to display the character virtue of humanity, including empathy and compassion. Surgeon A explained:

Caring for a learner involves caring for them as a human being. I ask questions like, How are you doing? Are you overwhelmed? How’s life going? Are your career goals being met?

Mattering also includes prudence, keeping the learner in mind while teaching. Surgeon B explained:

I try really hard to articulate the thought process behind every single move that is made intraoperatively so that my residents understand the rationale for a specific approach or technique or maneuver. This is in response to one of my mentors who didn’t like to articulate his rationale for certain moves, but would say instead ‘why didn’t you read my paper on this’? He’d say, ‘You can figure that out on your own’. Because of this, I do articulate during procedures so that hopefully the residents can understand- not just that we do things in a certain way,- but why we do things in a certain way.

Integral to helping residents feel they matter is respecting their professional judgment and involving them in colleague-type conversation when possible. Surgeon K described:

In an effort to bring trainees into the learning process and make decision-making a collaborative effort, I want them to feel involved. I wonder out loud and say things like, ‘I’m not sure what the right thing to do is, these are some options that I see. What do you see?… Especially for junior residents, it’s really empowering for them to have a conversation peer to peer, as opposed to a true hierarchy. It flattens things a little bit.

Close Social Relationships: Deriving Satisfaction through Individualizing Teaching

One way to demonstrate mattering is through developing a strong teacher–learner relationship. Learners prefer working with attendings who individualize teaching [7,8]. Individualizing teaching means scaffolding and adapting learning based on learning needs, with the goal of building autonomy, competence, and confidence. It necessitates developing a strong relationship through meaningful connections with each learner.

Teaching style can be adapted to meet the individual needs of trainees, highlighting the importance of personalized education with specific learning objectives for each trainee. Surgeon J said:

What I try to do with my learners is talk to them individually, based on how they prefer to communicate in their learning style. In other words, I think of myself as a chameleon and try to adapt to the environment and person that I’m talking to. The way I teach one person may be different from the way I teach another. I’m proud of being proactive about teaching in the operating room. Every time I do a case with a learner, no matter what level of learning they’re at, I think about what their learning objectives are, and I specifically ask them to articulate what they want to learn.

Recognizing the varying skill and confidence levels of trainees and adjusting teaching strategies accordingly is a part of individualizing teaching. Surgeon I described that:

I try to emulate my residency program director who was very intentional in pushing people’s abilities while also teaching to their comforts. His patience and willingness to cede control, to allow that development of autonomy, was unique to each individual trainee.

Surgeon D said this about the importance of getting to know residents who struggle as an individual, rather than just a resident who struggles:

For the resident that’s struggling, [it is important to] really get to know them and understand where they’re at. Learning more about the person as an individual really helped me reframe how I think about how to teach someone in a way that will be more receptive.

Individualizing teaching involves providing appropriate guidance based on residents’ needs. Surgeon G said:

Instead of a blanket approach, the caring aspect involves realizing that sometimes different effort needs to be made to meet that learner where that person is.

Furthermore, Surgeon C described concerted effort to be in tune with resident needs:

Everybody has their own priorities that they want out of their education. I try to be cognizant of that and not get frustrated or write someone off because they want to go into something other than my specialty. Everybody deserves the same effort and the same amount of passion for teaching, regardless of what their individual background or priorities are.

Surgeon A discussed what it meant to care for a learner:

Caring for a learner means that there is evidence that they’re getting from me what they need to be able to learn the skills that they are here to learn. It also means getting very clear about what the problem is if the resident is struggling. With a resident who’s struggling, I have to communicate that I care that he understands what we’re trying to get at for him to improve, and that we want him to be able to succeed.

Surgeon H explained how they use questioning to individualize teaching:

When I meet a learner, I ask them a few questions. I try to remember that [information] going forward, particularly when it’s related to their clinical interest. I ask them what their goals are.

Meaning and Purpose: Belief in the Worth of Residents as Humans

Another way to demonstrate mattering is helping residents maintain meaning and purpose through humanizing residency. Maintaining purpose means maintaining the values that are important to a trainee. Feeling purpose and mattering are key indicators of living a meaningful life [22].

Helping a resident maintain purpose included reframing gaps in learning from a deficit to a goal for the sake of good patient care. Surgeon E said:

The way he treated his trainees was based on his desire to make sure his patients got the absolute best care possible, and everything built toward that. So if you did something that was disappointing to him, it was disappointing to him because it meant that his patient was potentially not getting the best care possible… [Understanding] that’s what made me okay in the moment.

Supporting meaning and purpose also involved reframing learning away from the textbook and toward the individual patient. Surgeon F explained:

I help a trainee to gain sight, to pay attention to the right things. That’s what training is all about. In the operating room all you see is a particular body cavity; everything else is draped off, literally. You have a hyper focus on, for example, the gallbladder. But obviously the patients don’t want us to view them as a broken part and I think with burnout you might hear a comment like ‘how’s the gallbladder in [OR] 5?’. So I help residents attend to or learn to change the aperture. Sometimes we must be very narrowly focused. ‘Where is the common bile duct? Stay away from it’. And then other times I need them to view Mrs. Smith as a human being and understand her needs and worries and anxieties. Right now, she’s not just a sick gallbladder, she’s a person who has come here for care.

This qualitative study explored how attending surgeons promote resident flourishing in the clinical learning environment. Interviews with 11 surgeon educators from diverse institutions revealed that intentional teaching toward flourishing is characterized by three interrelated themes: acting to promote good through mattering, deriving satisfaction from individualizing teaching, and belief in the worth of residents as humans. See

Table 3. Synthesis of results’ themes.

Theme	Evidence and Implications
Virtue	Viewing residents through various lenses creates the opportunity to consider the whole person. When the resident is viewed as a trainee, colleague, and human being—it helps them feel that they matter and can make meaningful contributions.
Close social relationships	Individualized teaching approaches help to foster meaningful relationships between attendings and residents, creating more opportunities for learning and growth. This approach provides needed support for residents in times of struggle and demonstrates caring for the learner and belief in them as a surgeon.
Meaning and purpose	Stepping back allows for trainees to gain perspective on providing the best patient care, having the space to see the patient as a unique and vulnerable individual. In feeling a sense of purpose toward patient care, residents find meaning and continue to build on feelings of “mattering” in the learning environment.

for a synthesis of the results’ themes.

4. Discussion

This study offers insights into how surgeon educators intentionally create conditions for resident flourishing—an outcome increasingly recognized as aspirational in surgical training. Compared to traditional “pimping” or rigid Socratic methods, teaching for flourishing emphasizes psychological safety, trust, and learner dignity—conditions shown to support deeper learning and retention. This approach fosters intrinsic motivation, encourages critical thinking, and cultivates professional identity development in ways that adversarial models often undermine [25]. While much prior work has focused on mitigating burnout [2,5], the findings highlight how teaching toward flourishing encompasses dimensions of meaning, virtue, relationships, and life satisfaction within the clinical learning environment. Fostering meaning during residency is a vital antidote to burnout [26].

Surgeons have a unique capacity to shape the training culture [4,5]. When educators demonstrate that learners matter—that they are valued as people and as professionals—it creates motivation for meaningful engagement. Participants in our study described teaching approaches that encouraged resident judgment and created moments of collaborative clinical reasoning. These acts were seen not as pedagogical strategies alone but as expressions of character and virtue, particularly humility, humanity, and respect.

Individualizing teaching emerged as both a relational strategy and an educational imperative. Importantly, surgeons recognized that even struggling residents benefit most when teachers begin by affirming their worth and potential. Finally, surgeon educators described a strong desire to preserve meaning and purpose in the practice of surgery. In a high-pressure environment where dehumanization can take root, the best teachers helped residents see patients—and themselves—as full persons. They reframed error not as failure but as part of a developmental journey in pursuit of excellent care. These educators taught not only technical steps but professional identity, ethical reasoning, and the value of empathy.

One limitation of this study is that flourishing is an aspirational state that goes beyond mere well-being. Consequently, researchers have not yet examined what teaching practices aimed at fostering flourishing look like in action. Some may consider the small sample size a drawback of this study. However, the generalizability of qualitative research differs from that of quantitative research. Qualitative research focuses on naturalistic generalizability, the purpose of which is to resonate with the experiences of those studied, and transferability, which allows for readers and researchers to apply these findings to their contexts [27]. Future research could investigate how institutional structures can support teaching practices centered around flourishing.

Together, these findings suggest that fostering flourishing in surgical training requires intentional effort, relational depth, and virtuous practice. By highlighting the ideas of mattering, individualizing learning, and affirming meaning, educators can create a training environment that fosters fulfillment, resilience, and competence for the next generation of surgeons.