Learning to think like a surgeon, and learning to be recognized as one.

Four processes, not one

Surgical education tends to treat competence as a single thing a learner either has or lacks. It is more useful to distinguish four related processes. The first three are abilities the learner must develop. The fourth also depends on the people and systems doing the evaluating.

Not a ladder. Knowledge, judgment, and the ability to show your reasoning grow together and feed one another; a diagram simplifies what the writing around it can hold.

All four are important, but they are not interchangeable, and one of the central problems in medical education is that we often fail to distinguish among them. We teach knowledge explicitly. We expect clinical judgment to develop through experience. We assess competence through observable performance. And we assume that our recognition of competence is an accurate reflection of the underlying ability.

Each of those assumptions deserves examination.

Making the hidden curriculum visible

The gap between demonstrating competence and being recognized as competent becomes especially consequential for learners who have not intuitively absorbed the unwritten expectations of surgical culture. That may include:

• Neurodivergent learners, including those with ADHD or autism.
• International medical graduates navigating unfamiliar professional and cultural expectations.
• First-generation physicians, who may have had less access to informal mentorship and professional socialization.
• Learners from backgrounds historically underrepresented in medicine.
• Anyone whose cognitive processes, communication patterns, or prior experiences differ from those implicitly favored by their training environment.

These groups are not interchangeable, and not everyone within them experiences the same challenges. The useful question is how educational structures and assessment practices interact with individual differences.

The solution is not simply teaching learners to conform more effectively. Educators have three responsibilities.

We should not simply teach learners how to succeed within the hidden curriculum. We should also examine which elements of that curriculum deserve to survive.

This work sits alongside #ILookLikeASurgeon and #UnmaskMedicine. Representation asks who is seen as belonging in surgery. Education and assessment ask whose competence is recognized once they are there. The questions are different, but they are not separate. How a training culture responds to distress and vulnerability is part of the same curriculum, and it shapes whether learners feel safe asking for help; that thread continues on Mental Health in Medicine.

#FOAMsurg and Think Like a Surgeon

Medical education often emphasizes what learners need to know without explicitly teaching the cognitive processes involved in applying and communicating that knowledge. Think Like a Surgeon makes those processes visible. It teaches learners how to:

• Recognize important clinical patterns and distinguish superficially similar conditions.
• Organize information into useful mental models.
• Identify the findings that actually change management.
• Recognize uncertainty and know when more information is necessary.
• Anticipate complications and develop contingency plans.
• Structure a clinical assessment and management plan.
• Make clinical reasoning audible to colleagues, supervisors, and examiners.
• Use feedback, reflection, retrieval practice, and deliberate practice to improve.

These skills should be taught intentionally rather than left to chance.

My own experience with ADHD has made me particularly attentive to the difference between understanding something and communicating that understanding in the sequence another person expects. But this is not an initiative for people with ADHD. The objective is instructional design that makes complex learning more accessible to a broad range of learners.

We are not reducing the standards of surgical education. We are making the path to meeting those standards more explicit.

From curating information to developing judgment

I first proposed #FOAMsurg in 2017 as a way to organize and curate the surgical education already scattered across the open web. Much of the raw material still comes from things I built for myself during residency: comparison tables, “most common” lists, operative sequences, clinical discriminators, and the memory hooks that finally made things stick. But the initiative has evolved, from organizing existing resources toward developing learning experiences grounded in how people actually learn.

There are already excellent sources of surgical information. I am interested in helping learners transform information into knowledge, knowledge into judgment, and judgment into effective clinical practice.

And in how that competence is demonstrated and recognized within surgical training. That distinction is what makes this more than another collection of board-review materials.

Teaching lanes

Think Like a Surgeon is organized into repeatable formats. A piece can belong to more than one lane. These are being built now and will be linked here as they are published.

Learn with me: Oral Boards / Think Out Loud

The American Board of Surgery Certifying Examination asks surgeons to demonstrate clinical judgment through organized, spoken decision-making. That makes it a useful framework for teaching cognitive and communication skills that should be developing throughout residency, not something to assemble in the final months before the exam.

If the test is really about trust and safety, then safety is what we should be thinking about from day one.

The objective is not to teach residents to recite polished answers that create an impression of competence. It is to help them develop sound clinical judgment and communicate that judgment clearly. The six-part structure below is the one I use for my own preparation. It is meant to be useful to interns and medical students, not only graduating chief residents. The ability to articulate safe clinical reasoning should develop across all of training.

1. Clinical scenarioThe presentation, as it arrives: incomplete, time-pressured, and not yet labeled.
2. Opening movesWhat you do first. The stabilizing and information-gathering steps that come before a diagnosis or an operation.
3. Do-not-miss considerationsThe checklist that lets a fast, pattern-recognizing brain move quickly without skipping a safety-critical step.
4. Key decision pointsThe thresholds and findings that actually change management.
5. Making the reasoning audibleExaminers, teachers, and teams cannot see what you are thinking. Narrating real reasoning is not performance; it is how others assess its safety and logic.
6. Complications, alternatives, and bailoutsWhat could go wrong, and what is in your toolbox when it does.

Prep for oral boards with me

I am preparing for the spring 2027 Certifying Examination, and I am doing it in public. The calendar below is my own study plan, shared so that others can prepare alongside it. The target is to be exam-ready by March 1, 2027. The design draws on retrieval practice, spaced repetition, interleaving, progressive complexity, and feedback, and it assumes a variable clinical schedule.

Everything in this program is educational review for examination preparation. It is not clinical guidance.

How people actually learn

One popular idea in education is that each of us belongs to a fixed category: a visual learner, an auditory learner, a kinesthetic learner. Learner preferences, accessibility needs, and cognitive differences matter. But there is not convincing evidence that matching instruction to a supposed fixed learning style improves learning outcomes.

The methods in this initiative are grounded in more defensible learning science, and I try to be clear about which approaches are supported by evidence and which are my own educational hypotheses.

Educational effectiveness is not simply a matter of choosing the right content-delivery format. How learners engage with information, retrieve it, apply it, receive feedback, and revisit it over time can be more consequential.

A longer essay on this question is in progress: The Learning Styles Myth: What Actually Helps Us Learn? It will appear in Writing when it is ready.

What exists now, and what is coming

The #FOAMsurg materials themselves are being built. In the meantime, these are the educational resources already on this site and the writing that is underway.

Writing in progress

Essays from the Think Like a Surgeon series, listed here so you can see where this is headed. Titles will become links as pieces are published.

• How to Think Like a Surgeon From Day OneThe primer for the series.
• Show Your Work: Make Surgical Reasoning AudibleWhy good judgment often has to be narrated to be assessed.
• Oral Boards Are a Reasoning Scaffold, Not Just a TestUsing the exam format years before the exam.
• Do-Not-Miss: The Checklist for Fast Surgical BrainsChecklists as a counterweight, not a remedy.
• The Hidden Curriculum of Surgical JudgmentWhy restraint is praised as maturity and rarely rewarded as competence.
• The Learning Styles Myth: What Actually Helps Us Learn?Learning science beyond visual, auditory, and kinesthetic labels.