From Tradition to Wellness: A Systematic Review of Changing the Surgical Training Culture in Canada

Abstract

French

Introduction

Surgical training, historically characterized by long hours, hierarchical culture, and critical feedback, has been associated with burnout and mental health challenges. Reforms, including duty-hour limits, competency-based education, and initiatives promoting wellness, equity, and psychological safety, have begun reshaping training in Canada. This review provides a national overview of these cultural shifts, mapping recommendations for best practices and research.

Design

A systematic review identified studies on Canadian surgical residency culture. Two reviewers independently screened and extracted data, with risk of bias (ROB) assessed.

Results

Twenty-one studies were included. Key themes were wellness and mental health (19 studies), feedback and learning environments (20), evolving surgical culture (17), equity, diversity, and inclusion (12), duty-hour reforms (14), and international transferability (8). ROB was low in 44.00%, medium in 36.00%, and high in 20.00% of studies.

Discussion

This review of 25 studies highlights evolving themes in Canadian surgical training culture. Traditional endurance-based models are shifting toward inclusivity, wellness, and equity, with increasing attention to mental health, mentorship, and structured feedback. Duty-hour reforms, parental leave policies, and competency-based initiatives indicate generational and structural changes, though implementation varies across programs. Studies emphasize culturally responsive mentorship, psychological safety, and systemic supports to improve learning environments. While Canadian experiences provide valuable insights, differences in legal, institutional, and cultural contexts limit direct transferability internationally. Recommendations include implementing fatigue management plans, mentorship, simulation-based learning, and national coordination to foster a sustainable, learner-centered surgical culture.

Conclusion

Canadian surgical training is evolving through duty-hour reforms, wellness initiatives, and equity-focused policies. While progress has been made, challenges remain in mentorship and cross-provincial consistency.

Keywords

surgical culture surgical training surgical education surgical residency

Introduction

Surgical training has traditionally involved long hours, steep hierarchies, and feedback too often rooted in criticism and shaming.^1,2 Once seen as essential for resilience and technical skill, these practices are now linked to burnout, mental health challenges, attrition, and patient safety concerns.^3,4

Over the past two decades, structural and cultural changes, including duty-hour limits, competency-based medical education, and initiatives addressing mistreatment and psychological safety, have begun reshaping residency training, although adoption varies by province and program.² Among retired American College of Surgeons members, over half (52.4%) wished they had done parts of their career differently, most wanting more family time and prioritizing well-being (23.9%).⁵ While studies have examined duty hours and wellness, no synthesis maps broader cultural shifts nationally. The historically paternalistic culture appears to be shifting with increasing focus on diversity, equity, inclusion, and wellness.⁴

A systematic review is therefore timely, providing an overview of Canadian surgical training trends from traditional endurance-based models to frameworks emphasizing wellness, equity, and professionalism, mapping recommendations for best practices and future research.

Methods

This review followed the PRISMA guidelines for systematic reviews (Supplementary Figure 1).⁶ A search of PubMed, Ovid MEDLINE, and CINAHL was done, from database inception to September 15, 2025, using keywords related to surgical training, residency, wellness, duty hours, equity, and professional culture. Full search strategies are in Supplementary Figure 2. Eligible studies included original research and commentaries on cultural, structural, or policy aspects of surgical residency, including wellness, equity, or learning initiatives. Studies not focused on surgical residency, or the Canadian context, were excluded.

Title and abstract screening, and full-text review, were conducted independently by two reviewers (S.B.AM and R.E.), with disagreements resolved by discussion. Bibliographies were also screened.

Data were extracted using a standardized spreadsheet. One reviewer (S.B.AM) collected study characteristics, populations, interventions, outcomes, and context, with a second reviewer (R.E.) verifying accuracy. Extraction targeted factors shaping surgical training, including professional norms, workload, well-being, equity and inclusion initiatives, teaching and evaluation approaches, regional variability, and recommendations.

Risk of Bias Assessment

Risk of bias (ROB) was assessed. Observational cohort studies were evaluated using the Newcastle-Ottawa Scale (NOS).⁷ Non-randomized observational studies were assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool.⁸ Perspective articles were appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.⁹ Qualitative studies were evaluated with the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research.¹⁰

Results

The search yielded 25 articles (Table 1). A total of 17 articles^1,3,4,11-24 examined the evolving definitions of surgical culture from traditional hierarchies towards wellness, inclusion, and mentorship. Eighteen^{1-4,11,14,16,20-30} focused on duty-hour reforms, including parental leave (n = 7)^{4,11,14,16,21,24,27} and reduced call hours (n = 9).^{1,2,4,11,20,21,25,26,28} Wellness and mental health initiatives emerged as a theme in 21 articles^{1-4,11-22,24-28} with the mention of structured initiatives that address burnout (n = 7)^{1,2,4,11,19,21,27} and discrimination (n = 5)^{11,13,16,24,27} through mentorship and mindfulness programs (n = 2).^1,19 Thirteen addressed equity, diversity, and inclusion^{1,2,4,11,13,14,16,19,21,24,25,27,31} mainly by advising the creation of structured mentorship groups (n = 3)^11,16,19 and inclusive training (n = 10).^{1,4,11,13,16,21,24,25,27,31} Feedback and the learning environment were discussed in 24 articles^{1-4,11-16,18-31} through the discussion of competency-based training (n = 2),^23,25 mindfulness (n = 1)¹⁵ and the use of digital learning (n = 2).^3,12 Finally, 11 explored global variation and transferability.^{2,4,14,20,21,24,25,27-29,31} Notably, only one article provided specific recommendations for Canada.²

Table 1.

Overview of 25 Studies Included in Review.

Author, Year	Type of Study	Methods	Changing Definitions of “surgical Culture”	Duty-Hour Reforms: Lessons and Controversies	Wellness and Mental Health Initiatives	Equity, Diversity, and Inclusion	Feedback and Learning Environment	Global Variation and Transferability	Recommendations
Urowitz, 2003	Qualitative Research	- Description of the history and role of PAIRO in negotiating duty hours with teaching hospitals in Ontario		- Limits on duty hours improve safety and well-being but may reduce exposure to a wide variety of medical conditions - Require use of attending physicians or other health professionals for tasks previously performed by residents			- Educational and research time increased due to duty-hour limits
McInness, 2918	Qualitative Research	- Online survey of all Canadian plastic surgery residents and program directors		- Majority of residents (69%) and program directors (70%) oppose 80-h weekly limits - Residents willing to forgo post-call rest for surgical experience - If 80-h limits imposed, program directors largely feel training duration should be increased - Perceived medical errors due to post-call fatigue: 49% of residents, 40% of program directors -Perceived surgical errors due to post-call fatigue: 26% of residents, 30% of program directors - Residents and program directors perceive a culture that expects working post-call to master surgical skills	- Residents report decreased quality of life and learning capacity when working post-call - Residents somewhat agree that operative ability and ward management suffer post-call		- Residents motivated to work post-call to maximize educational opportunities	- Canadian provincial regulations vary in work hour and post-call restriction
Sudarshan, 2012	Retrospective cohort	- Survey of all Canadian general surgery residents (27 questions) assessing perceptions of work-hour restrictions and night float system		- Majority of residents work 75−100 h/week, 15% > 100 h/week - Seniors more likely than juniors to believe limiting hours decreases operative exposure, prevents completion of Royal College objectives, and could extend residency to 7 years - Concerns about patient safety, communication gaps, and continuity of care remain - Work-hour limitations create controversy and concern in residency programs - Residents perceive that long hours are required for adequate operative exposure and mastery of surgical skills			- Concerns about decreased bedside teaching and outpatient clinic involvement	- Canadian context differs: no national restrictions yet, ongoing deliberations at provincial/national level
Aminazadeh, 2012	Prospective Interventional	- Survey of 600 Canadian surgical residents - Assessed stress levels, causes, and coping mechanisms		- Time pressures and number of working hours identified as main stressors - Insufficient sleep and frequent call were most stressful components	- Residents used coping mechanisms such as staying optimistic, engaging in enjoyable activities, consulting others, and exercising - Women more likely to seek help and get checkups	- Graduates of foreign medical schools reported higher stress related to working conditions, residency program, discrimination, and personal and family safety	- Pressure from examinations and evaluations rated as highly stressful - Conflicting demands from coworkers and exposure to hostility or conflict also contributed to stress	- Differences by specialty noted
Akuffo-Addo, 2024	Retrospective cohort	- Qualitative study - Purposive sampling for sex, geography, and training year - 27 participants: 18 Black medical students, 9 residents, from 17 Canadian medical schools - Recruitment through posters, social media, and snowball sampling - Online semistructured Zoom interviews, 45−60 min - Demographics and experiences collected - Inductive reflexive thematic analysis of transcripts	- Surgery perceived as mentally, emotionally, and physically demanding - Culture emphasizes dedication, sacrifice, and neglect of personal needs - Negative perceptions: arrogance, tunnel vision, hierarchy, god-like complexes - Certain cultural traits seen as necessary in high-stress OR, others as contributing to toxic environments - Shifts observed toward collegiality and supportive work environments	- Duty hours restricted in Canada (max 26-h shift, max call 1 in 4 days) but often exceeded due to staff expectations and low co-resident numbers - Suboptimal call schedules and excessive weekly hours deter students from surgery - Suggestions included adjusting duty hours and improving support for work-life balance - Recommendation for transparent maternity leave processes across all surgical speecialties	- Feelings of isolation and lack of belonging among Black medical students and residents - Microaggressions, verbal abuse, and over-policing by staff harm mental health - Female participants face gendered barriers and anticipate challenges balancing family and career - Suboptimal work environments and sleep deprivation increase stress and deter pursuit of surgical careers	- Lack of mentorship and representation as major barrier - Racism deters program completion - Intersection of race and gender exacerbates barriers - Pathway programs for Black learners - Holistic applicant review including advocacy and lived experiences - Mandatory implicit bias and antiracism training for faculty and staff - National mentorship programs and surgery interest groups	- Residents report lack of safe spaces and insufficient support - Staff often fail to address microaggressions or overt discrimination - Call for faculty and staff training to create equitable, supportive environments - Mentorship traits (honesty, confidentiality, advocacy) valued more than race concordance
Alam, 2022	Retrospective cohort	- Cross-sectional nationwide survey of Canadian surgical residents - Recruitment: All 17 programs; 122/650 responded (19%) - 51-question survey: demographics, mental health, education, health habits, wellness office use - Outcomes: perceptions of education quality, mental health, lifestyle changes, wellness program effectiveness	- Reduced in-person teaching, increased online teaching, and redeployment to COVID-19 wards - Delivery of surgical education altered, affecting perceived training quality - Residents had more free time but less hands-on surgical experience, raising concerns about graduate competency		- 41% reported more anxiety - 25% felt happier - 61% felt lonelier and less connected to friends - Sleep: unchanged/improved in 37%, worsened in 26% - Alcohol: 38% increased use; volume up 48% - 62% had more time for physical activity, but no significant change in activity levels - Time seated nearly doubled; computer time up 93% - Only 14% benefited from wellness programs despite 93% awareness		- 94% supported online teaching as a complement to in-person teaching - 43% preferred online teaching as a replacement - 39% found online teaching comparable, 25% superior, 36% inferior to in-person teaching - Virtual simulators suggested to supplement learning
Brown, 2021	Retrospective cohort	- Mixed-methods study on gender-based discrimination (GBD) among surgical residents - Quantitative phase: Survey of residents from 7 University of Calgary surgical programs; assessed frequency, type, and setting of GBD using adapted U.S. survey - Qualitative phase: Semi-structured interviews with female residents reporting GBD, conducted by non-clinician researcher - Interviews: audio-recorded, transcribed verbatim, de-identified, analyzed inductively with thematic analysis, guided by feminist theory	- Surgery perceived as a “boys’ club,” pressuring women to work hard to fit in - Female residents feel the need to be “one of the boys” and avoid being seen as sexual targets - Women surgeons stereotyped as either “hardcore, cutthroat” or “incompetent” - Culture creates systemic challenges with patients, family, and staff - Nurses and staff often show preferential treatment toward men; women adopt strategies like “girl flirting” to earn respect - Surgical culture impacts both patient care and resident well-being		- GBD experiences contribute to stress and negatively affect well-being - Female residents feel they must “work twice as hard” to gain respect - Mistreatment, bullying, and harassment from nurses and staff cause emotional strain (residents sometimes cried)	- Women residents experience significantly more GBD than men (83% vs 27% at least monthly) - Gender affects learning opportunities and feedback; women report reduced operative autonomy and negative supervisor feedback - Patients, family, and staff show differential respect and authority based on gender - Gender minorities face structural oppression and power asymmetry - Gender operationalized as socially constructed; nonbinary identities acknowledged	- Women receive feedback more often focused on personal traits than clinical performance (50% vs 26% men) - 32% of women felt gender negatively influenced feedback from superiors (0% men) - 28% of women reported fewer learning opportunities than other genders (14% men) - Women face OR and ED challenges: interference with operative participation and denial of instruments/orders
Dussault, 2014	Qualitative Research	- Historical and policy review of Quebec duty hour reforms (1987−2012) - FMRQ grant program monitored impact of 16-h schedules on training, patient care, and resident wellness - Comparative analysis of 24-h versus 16-h call schedules: calls, hours worked, gaps in coverage		- Quebec implemented 16-h maximum in-house call for all residents on 1 July 2012 - Previously, 24-h call schedules were standard - Change followed legal arbitration, labor negotiations, and sleep deprivation evidence - Total hours worked did not decrease; schedules were reorganized - Similar 16-h schedules exist for first-year residents in the US, UK, Australia, and New Zealand	- 16-h schedules aim to reduce sleep deprivation and associated risks: cognitive decline, poor clinical performance, medical errors, needle-stick injuries, car accidents - Research grants provided to evaluate impact on residents’ quality of life, health, and wellness		- Concerns: continuity of care, missed procedural opportunities, increased handovers, potential shift-work mentality - Emmphasis on reviewing teaching and monitoring approaches under new schedules
ElAbd, 2025	Retrospective cohort	- Cross-sectional online survey of McGill surgical residents (May 2024)	- Surgical training historically emphasizes perfection; mistakes often addressed with blame and shame - Shame-based learning (SBL) remains common, despite most trainees considering it unnecessary - Shaming comes from superiors, peers, allied health professionals, patients, and junior learners - Recommendation: shift toward psychological safety and constructive feedback to reduce toxic culture	- 43% of residents exceeded maximum call per period in the last academic year - 36% reported institutional call duty regulations were not followed - Higher professional fulfillment and grit scores linked to greater satisfaction with working hours and duty regulations	- SBL linked to: loss of self-confidence (63%), depression/anxiety (37%), professional isolation (33%), poor job performance (33%), thoughts of suicide (4%) - Experincing or observing SBL associated with higher burnout scores - Burnout characterized by emotional exhaustion, depersonalization, diminished personal accomplishment - High grit scores protective against burnout; associated with increased professional fulfillment - Well-being promotion: workshops, peer-support networks, resilience initiatives, institutional reforms	- Female residents more likely to view SBL as necessary (75% vs 25%; p = 0.025) - No significant gender differences in burnout, grit, or professional fulfillment, suggesting positive cultural shift - Highlights need for unbiased, supportive work environment to reduce burnout and gender disparities	- Constructive feedback preferred over SBL: emphasizes behaviors, actionable advice, and learning opportunities - Mentorship crucial for navigating challenges and building resilience - Psychological safety important: trainees should feel comfortable asking questions and admitting uncertainty - Residents with higher grit less likely to shame others, promoting positive learning culture
ElHawary, 2023	Retrospective cohort	- Cross-sectional observational survey study - Participants: 89 plastic surgery residents from all Canadian programs - 28-item questionnaire: demographics, training level, career goals, surgical case exposure	- Shift toward gender equality in surgical training noted - Female residents report gender negatively affects surgical exposure despite similar case numbers - Indicates ongoing cultural challenges related to gender perceptions in training environments	- 8 residents (9%) took parental leave during training training - Average leave: 20 ± 18 weeks - Females took significantly longer leave than males (36 ± 10 weeks vs 4 ± 1 weeks; p < 0.001)	- Female residents more likely to report decreased interest in plastic surgery during training (29.4% vs 7.1%; p = 0.024) - Gender bias identified as a contributor to burnout among female residents	- No difference in logged surgical case volume between genders - 39% of female versus 4% of male residents felt gender limited surgical exposure (p < 0.001) - Career interests differ: males favor academic careers, females favor community practice (p = 0.024) - Lack of female mentorship may contribute to inequities	- Higher self-rated proactivity in the OR associated with increased reconstructive case exposure (B = 33.34; p = 0.039) - No gender difference in self-rated proactivity (7.7 males vs 7.3 females; p > 0.05) - Emphasizes importance of proactivity and mentorship to enhance learning experiences	- Nationwide Canadian study including all 11 plastic surgery programs - Generalizability to other countries not assessed; nationwide inclusion improves internal generalizability within Canada
Hours, 2013	Retrospective cohort	- Mixed-method - Semi-structured interviews with 18 National Steering Committee members - National survey of residents, postgraduate deans, program directors, and hospital administrators - Analysis of 76 current and historic provincial housestaff collective agreements - Literature review of 38 systematic reviews on six themes: Patient Safety, Medical Education, Health Systems Performance and Economics, Professionalism, Resident/Faculty Health and Wellness, Procedural Disciplines - Two-day Canadian Consensus Conference with 77 experts/stakeholders for consensus-building		- Shift lengths generally 24−26 h; Quebec limited to 16 h post-arbitration - Weekly hours variable (60-90 h), some allow averaging - Call frequency mostly 1 in 4 days in-house, 1 in 3 out-of-house - Duty hour reforms include fatigue risk management plans (FRMPs) - International comparisons: US 80 h/week, 24-h max (16-h first-years post-2011); EU 48 h/week max; New Zealand 72 h/week max, 16 consecutive hrs/day; Australia advisory 50–70 h/week with fatigue management - Traditional call models linked to burnout, obesity, diabetes, cardiovascular disease, sleep deprivation, accidents, cognitive and emotional impairment - Survey data: 70% of residents experience prolonged sleep deprivation, 67% use caffeine, 20% use sleep medications - Fatigue affects cognitive, behavioral, empathy, motor skills, efficiency, accuracy, and potential error rates - Patient safety influenced by supervision, handovers, continuity, and institutional differences; most residents report no serious errors or actual harm - Evidence shows little or no impact of consecutive duty hour restrictions on patient outcomes - Resident fatigue and safety also influenced by staffing, workload, supervision, patient complexity, and communication; duty hours alone insufficient - Mixed evidence on impact of duty hour regulations on training, exams, operative experience; educational innovations complicate assessment - Surgical training disproportionately affected by duty hour regulations: reduced procedural exposure, operative volume, emergency experience - Survey: 73% of surgical residents report adequate procedural training; mitigation strategies include protected sleep, simulation curricula, competency-based training, optimized clinical time	- Traditional 24 + hour duty periods risk residents’ physical, mental, and occupational health - Duty hour reductions alone insufficient to improve well-being; comprehensive approaches needed	- Human rights considerations influenced Quebec ruling limiting consecutive hours to 16 - Residents’ dual roles as learners and care providers highlight the need for fair work conditions	- Duty hour regulations affect educational outcomes; impact on academic performance unclear - Residency education should be redesigned to maximize learning, include self-assessment, fatigue management, and handover skills	- International duty hour regulations and enforcement vary - US: ACGME-regulated, strong patient safety focus; stricter limits for first-year residents - EU: EWTD 48 h/week max; enforcement varies by country - New Zealand: 16-h consecutive limit, structured rest periods - Australia: advisory limits with fatigue management principles	- Recommendations adopt a comprehensive, integrated approach to resident duty hours, focusing on safety, wellness, and education - Develop program-specific Fatigue Risk Management Plans (FRMPs) considering consecutive hours, workload, and individual fatigue susceptibility - FRMPs regularly monitored, evaluated, and updated; national review every two years - Implement infrastructure and monitoring: personalized risk assessments, wellness initiatives, modified duties as needed - Train residents in fatigue recognition and mitigation; local oversight via fatigue officers; national toolbox of strategies - Ensure all a;;duty hours provide meaningful learning; service demands should not impede academics - Use simulation (standardized patients, virtual, high/low fidelity) for foundational knowledge, rare cases, competency-based skills - Include curricula on self-assessment, fatigue management, handover, and communication skills - Allow flexible training models (night float, cross-coverage) without compromising competencies - Centralized evaluation and resource coordination through a pan-Canadian consortium - Maintain and share national toolbox of resources, schedules, and best practices
Jiang, 2025	Retrospective cohort	- 28 Items	- Female residents now >40% of matched candidates since 2008; changing generational attitudes highlight work-life balance and family planning - Family planning conversations remain taboo; students reluctant to discuss parenthood during residency interviews due to potential bias - Residents face stigma when requesting schedule accommodations for pregnancy, postpartum care, or new parenthood	- All programs disclosed maternity, paternity, and adoption leave policies - Maternity leave: 17–52 weeks; paternity leave: 24–72 weeks - 82% of programs offered paid parental leave - Vacation: up to 4 weeks; professional leave: 7–17 days - Sick leave: 15–365 days; rollover policies varied	- 88% of programs offered mental health coverage ($350–$2000 annually or unspecified) - Primary care coverage available in 41% of programs (eg, university health clinics) - Lack of clarity or access to healthcare resources negatively impacts resident well-being	- Lack of transparency in parental support policies can disadvantage residents navigating parenthood - Taboo around family planning and unclear policies affect all genders - Residents face accessibility challenges due to ambiguous student versus employee status, limiting access to university or hoospital benefits	- Mentorship in family planning is a critical support factor - Many residents lack mentors who openly model integrating parenthood with surgical training	- Canadian programs showed higher median transparency (19/28 items) than US programs (8/26) - Canadian parental leaves longer: maternity 17 weeks versus 14 days, paternity 24 weeks versus 5 days
Lie, 2021	Qualitative Research	- UBC General Surgery Program adapted schedules, teaching, and wellness during COVID-19 - Wellness initiatives: exercise programs, resident lounge, meals, virtual group workouts - Encouraged reflection and volunteer work	- Wellness a core value in UBC General Surgery residency even before COVID-19 - Program restructured during pandemic to prioritize safety, wellness, and community - Provided education on signs and symptoms of burnout - Residents encouraged to express feelings and reflections	- No information on parental leave provided - Resident schedules reformatted during pandemic to optimize efficiency, safety, and wellness - Residents divided into 3 groups rotating weekly: general surgery rotations, Resident Reserve Unit (RRU), and ICUs	- Wellness targeted in three domains: efficiency of practice, culture of wellness, personal resilience - Reserve teams created to reduce stress and allow rest when unwell - Daily meals, virtual group workouts, and wellness committee initiatives (exercise membership, resident lounge, snacks) provided - Weekly virtual meetings with program directors to discuss physical, emotional, and social challenges - Residents engaged in volunteer efforts and fundraising to foster purpose and resilience - Education on burnout signs and supportive structures encouraged help-seeking and minimized stress		- Weekly townhalls enabled residents to present ideas and adjust changes based on feedback - Didactic teaching reformatted: combined junior/senior sessions; twice-weekly shorter virtual sessions by chief residents and faculty - Residents redeployed to ICU received refresher courses - Routine, scheduled knowledge sharing reduced stress and kept residents up to date - Daily 5-min virtual presentations conducted across teaching hospitals
Maruscak, 2012	Retrospective cohort	- All surgical residents and faculty from two Canadian university-affiliated centers invited to complete online survey	- Surgical residency training has evolved due to work-hour restrictions and changing training environments - Current residents work under different conditions than predecessors, affecting perceptions of practice and career expectations - Generational differences exist between residents and faculty regarding benefits or drawbacks of work-hour restrictions - Increasing female participation is changing program gender mix and may influence surgical culture and expectations	- Work-hour restrictions include postcall relief and limited call frequency (1 in 3 home call or 1 in 4 in-hospital) - Residents expect fewer workdays per week and less frequent call rotations than current faculty - Residents more likely to leave hospital after postcall duties instead of continuing patient care - Residents plan to use parental leave more often than faculty; female residents more likely than males (51.8% vs 16.1%)	- Limiting clinical duty hours may reduce fatigue-related errors and improve training civility - Faculty acknowledge that shorter workweeks and fewer nights on call could decrease surgeon depression, burnout, and medical errors	- Increasing female participation in surgical residency noted - Female residents have different expectations regarding postcall duties and parental leave - Societal expectations and demands on female physicians differ from males, influencing anticipated work patterns.	- Faculty concerned work-hour restrictions may negatively affect resident education and future surgical career preparation - Residents’ training experiences shape their expectations for future practice patterns	- Canadian residents work under more liberal duty-hour guidelines than U.S. or European counterparts - Observations may have limited relevance outside Canada or in nonacademic settings
Miazga, 2025	Retrospective cohort	- Prospective cohort study - Participants: 12 of 61 eligible OBGYN residents at University of Toronto; 8 completed the course - Intervention: 12-week modified mindfulness-based cognitive therapy (MBCT); 30-min weekly group sessions + 15-min daily home practice - Qualitative measures: focus groups and semi-structured interviews exploring barriers, enablers, and mindfulness integration into OR	- Mindfulness integrated to help residents cope with stress, focus during operations, and prevent negative spillover - Residents reported mindfulness could foster a positive culture shift, valuing non-clinical skills in surgical training - Incorporation signaled that self-care, reflection, and emotional regulation are important aspects of surgical culture		- Mindfulness curriculum significantly decreased resident anxiety - Residents reported improved stress coping and emotional regulation in clinical and personal settings - No significant changes in burnout, though baseline levels were high - Mindfulness viewed as supportive for mental health, while systemic contributors to burnout were acknowledged		- Mindfulness helped residents accept feedback without personalizing it - Residents reported increased presence during patient care and interactions - Group-based program fostered accountability and peer support
Mocanu, 2020	Retrospective cohort	- 129-item electronic survey	- Culture of inequality influenced by gender and racial/ethnic biases - “Formal relationships with staff” ‘ disadvantaged women in networking, research, and operative training - Respondents suggested fostering a culture of equality based on justice and transparency, free from discrimination	- Equal opportunities for parental leave, childcare, and career advancement should be provided to all residents, regardless of gender or visible minority status	- Female residents and visible minorities (VM) reported lower collegiality, poorer program fit, and feeling less valued - 41% of residents had considered quitting residency - Women more likely than men to consider quitting (50% vs 29.4%) - Women with VM status more likely to “at least usually” consider quitting (15.2% vs 1.5% of male non-VM residents)	- 82.4% of residents felt fostering diversity strengthens surgical programs - 78.1% acknowledged a diverse workforce is important for training and patient care - Perception of staff diversity lower for race/ethnicity (36.2%) and sexual orientation (33.8%) - Intersectionality highlighted female VM residents as particularly disadvantaged - Suggested strategies: acknowledge biases, establish strong mentorship, enhance role model pool, promote transparent merit-based recruitment, ensure equal opportunities	- Mentorship opportunities limited, especially for female and VM residents - Female residents valued same-gender role models; VM residents valued same race/ethnicity role models - Nearly 1 in 2 female VM residents reported lacking a mentor to help navigate residency - Residents perceived unequal training opportunities based on gender, race/ethnicity, or religion - Perception of competence affected: patients and staff more frequently dismissed female and VM residents’ expertise compared with male non-VM residents
Patel, 2018	Prospective Interventional	- Constructivist grounded theory study (qualitative) - Participants: 15 general surgery trainees	- Residents felt strong pressure to appear all-knowing, quick, decisive, and confident. - Surgical culture emphasized maintaining the ideal surgical persona, despite internal doubts or fears. - Trainees experienced identity dissonance between roles as learners versus surgeons. - A hidden curriculum conveyed implicit norms (eg, asking for help = weakness) that conflicted with formal teachings. - Impression management (Goffman) influenced behaviors and shaped professional identity development.		- Pressure to appear confident led to stress and anxiety. - Impression management demanded significant mental energy and impacted personal identity. - A “vicious cycle” of self-consciousness reduced confidence, increased tentativeness, and elevated stress. - Focus on appearing competent sometimes compromised patient care and contributed to burnout.		- Residents used impression management to influence evaluations and access learning opportunities. - Strategies included fabricating stories, staying silent, and avoiding help-seeking. - These behaviors hindered learning by limiting clarification, participation in rounds, and M&M discussions. - Hidden curriculum pressures often overrode formal teaching about asking for help.
Rajendran, 2022	Retrospective cohort	- University of Toronto General Surgery launched JuMP (Junior Mentorship Program) for PGY1–PGY2 residents in 2019–2020. - PGY1 residents were matched with PGY2 mentors by a PGY5 chief using standardized interviews.	- Mentorship is important for easing transitions and fostering a supportive surgical culture. - Peer mentorship enhances community and resident connection. - Personal connection and personality matching are key to successful mentorship and shaping training culture.		- Mentorship promoted wellness and supported mental health. - Mentors helped validate anxiety and guide residents through challenges. - Peer mentorship eased transitions into residency, indirectly supporting well-being. - Residents recommended formal mentorship sessions to enhance work-life balance and continuity of support.	- Limited mentorship access disproportionately impacts visible minority residents.	- Mentorship positively influenced performance, goal-setting, confidence, and work-life balance. - Mentees found the program at least slightly helpful in all four domains. - Both mentees and mentors benefited through career planning, academic guidance, and skill development. - Residents suggested formal scheduling and longitudinal mentorship to improve structure and continuity.
Romanchuk, 2004	Qualitative Research	- Descriptive perspective on Canadian surgical residency experience over time. - Compares historical 24/7 call schedules with modern duty-hour restrictions.	- Competence is not solely based on procedure volume or patient encounters. - Educational goals and objectives are predetermined and formally evaluated. - Residents are mentored in broader roles: communication, collaboration, scholarship, professionalism, management, and advocacy.	- Work-hour restrictions have been in place in Canada for about 10 years. - In-house call typically limited to 1-in-4 (24-h in-hospital shifts). - Home call usually 1-in-3, with residents responding from home. - Provisions allow relief from duties after 24-h calls, with some scheduling flexibility.	- Residents have increased protection from continuous patient-care demands. - More time is available for structured study and skill development beyond technical abilities. - Programs foster a “happier work setting,” believed to enh ance patient care.		- Residents have access to enhanced educational resources: skills-transfer courses, simulators, practice labs. - High resident motivation to learn and improve within limited time. - Predetermined goals enable structured assessment and mentorship across competencies. - Advances in surgical techniques improve procedure exposure and foster critical thinking on complex cases.	- Some educational resources are sourced from U.S. organizations indicating international sharing.
Scallan, 2025	Qualitative Research	- Constructivist Grounded Theory qualitative design - 21 Canadian surgical trainees/faculty who took maternity leave (2012-2022) across specialties	- Motherhood increasingly seen as enhancing surgical skill development (“motherhood advantage”) - Return from maternity leave prompts transformation in professional identity, challenging flawless, self-sacrificing surgeon ideals - Surgical culture remains shaped by perfectionism, long hours, and gendered expectations, but participants learned to set boundaries and prioritize tasks	- Challenges included call scheduling and childcare arrangements during maternity leave - Canadian parental leave policies offer 12–18 months through federal Employment Insurance, with some provincial salary top-ups - Participants recommended more flexible call schedules and phased returns to work to ease transitions	- Returning to surgical residency caused stress, fatigue, self-doubt, and mental load balancing work and parenting - Participants felt professionally and personally inadequate	- Persistent discrimination and microaggressions toward surgeon mothers reported - Gendered perceptions and jealousy from peers and supervisors noted - Biases and negative attitudes persist despite equity, diversity, and inclusion efforts	- Peer role models and senior resident advice aided navigation of challenges - Supportive discussions and mentoring normalized experiences and offered practical return-to-work strategies - Skill labs, lighter rotations, and part-time return facilitated learning and skill retention	- Variations in parental leave policies across countries may limit generalizability
Seemann, 2019	Retrospective cohort	- Mixed-methods study collecting quantitative and qualitative data on compassion fatigue among surgical trainees - Anonymous survey emailed to PGY-1 to fellows across multiple surgical specialties	- Surgical culture values being all-knowing and tough; showing emotion is often viewed as weakness - Emotional impact of surgical work is rarely openly discussed, creating a hidden curriculum limiting coping skill development - Fatigue is normalized; feeling tired and exhausted is common and commonly expressed among trainees	- Higher workload and frequent night shifts (eg, >80 h/week) are linked to increased risk of compassion fatigue	- High burnout and secondary traumatic stress reported; compassion satisfaction average - Most cope with stress through exercise; ∼25% use alcohol; only 6% sought counseling - Emotional encounters cause anxiety, irritability, fatigue, patient avoidance, and reduced empathy - Trainees mainly talk to partners, friends, colleagues; professional counseling rarely used - Support expressed for organized programs to prevent/manage compassion fatigue (debriefing, coping training) - Individual coping strategies: mindfulness, meditation, support networks - Organizational strategies: acknowledge provider well-being, mentorship, peer support, optimize work hours - Wellness interventions should include awareness and identification of problematic alcohol/substance use		- Trainees face barriers to discussing emotions with staff due to concerns about image and lack of approachable faculty.- Debriefing and internal reflection exercises were considered helpful. - Cultural expectations to appear competent and manage stress independently affect learning and emotional processing.
White, 2023	Perspective Article	- Perspectives/review article, not primary research - Evaluates competency versus proficiency, advocating for procedure-specific assessments to enhance readiness for independent practice	- Traditional Halstedian training used operative volume as a competency proxy - Modern education emphasizes competency-based education (CBD) over time or volume - Competency includes knowledge, technical skills, communication, and clinical judgment but is poorly defined in practice - Proficiency (autonomy))- differs from competency; graduation should target autonomy	- Reduced duty hours may leave trainees ill-prepared for independent practice - Duty hour restrictions cause unpredictable operative volumes, complicating competency assessment			- Non-technical (“soft”) skills often develop informally through experience, not formal teaching
Ying, 2023	Retrospective cohort	- Included Canadian medical graduates enrolled surgical programs (2000-2010) in 8 specialties (Cardiac, General, Neurosurgery, Orthopedic, Otolaryngology, Plastic, Urology, Vascular); Obstetrics/Gynecology excluded	- Female surgical trainees in Canada left training at higher rates than males (12.4% vs 6.1%) - Female trainee numbers steadily increased from 2000–2010, reaching nearly 40% of new residents by 2010 - Female attrition rates decreased over the 10-year period, indicating improvement - Equity in surgery depends on reducing higher female attrition rates - Growing numbers of female graduates and faculty may enhance recruitment and retention, creating a positive cycle	- Factors influencing attrition: work-hour restrictions, mentorship availability, parental leave, student debt, workplace environment - Training length may be extended due to research, graduate degrees, parental/personal leave, or remediation - Improved work hours, lower debt, resident unions, and better parental leave access may enhance recruitment and retention	- Causes of female surgical trainee attrition are multifactorial and cumulative - Gender-based discrimination, harassment, and abuse from patients and staff contribute to attrition	- Female trainees are an increasing proportion of surgical residents but have disproportionately higher attrition - Female trainees report decreased autonomy in surgical exposure - Minority groups (race, sexual orientation, gender identity) likely face discrimination but were not captured in this data	- Learning environment differences can either support or challenge trainees, influencing attrition rates - Programs with higher female trainee retention may offer valuable strategies for improving other programs	- Canadian surgical attrition rate: 8% overall; female trainees twice as likely to leave as males - US attrition rates: general surgery 20.8%, neurosurgery 11%, otolaryngology 6%, plastic surgery 3%, orthopedic surgery <1% - Pakistan single hospital attrition: 39% in surgical specialties - UK: 54% women in foundational surgical training, dropping to 30% in specialty training - Canada retains a higher percentage of female trainees compared to US, UK, and Australia
Zhu, 2025	Retrospective cohort	- Observational study analyzing 96 h of recorded lecture seminars (May 2020–Dec 2021) - Images coded by Fitzpatrick skin type (I–VI)6; included photos with visible skin; excluded nonhuman, radiological, illustrations, identifiable individuals				- Educational materials show gaps in skin tone diversity representation - Medium (Fitzpatrick IV–V) and dark (Fitzpatrick VI) skin tones underrepresented in resident images - 46% of residents desire more diversity in photos; 61% of faculty believe current inclusion is sufficient - Both groups agree on commitment to increase EDI opportunities (faculty 61%, residents 82%) - Integrating skin tone diversity into curriculum deemed essential for competency and equitable care	- Survey assessed faculty and resident perceptions of skin tone diversity - Residents perceive need for more diverse images; faculty believe current inclusion is sufficient	- Single-institution, Canada-specific study - Multi-institutional research needed to assess broader trends
Mohajeri, 2025	Prospective Interventional	- Prospective interventional study with 8 voluntary residents - Mentorship via tiered mosaic model: one main mentor plus optional supplemental mentors	- Residents exhibit high baseline stress and burnout - Stress and burnout measured using Perceived Stress Scale and Maslach Burnout Inventory - Quality of Life assessed with WHO-QOL-Bref - QOL improvements seen in physical, social, and environmental domains - Psychological domain improvements were not statistically significant between 12 and 24 months		- Mentorship focused on clinical skills, research, career planning, and personal development - Residents reported high satisfaction, valuing role models, support, and accessible help during challenges

There has been an increasing trend in the number of published manuscripts over time, with regular yearly publications since implementation of the Royal College Competency by Design: 2003 (n = 1),³⁰ 2012 (n = 3),^4,25,29 2013 (n = 1),² 2014 (n = 1),²⁶ 2018 (n = 2),^18,28 2019 (n = 1),²² 2020 (n = 1),¹⁶ 2021 (n = 2),^3,13 2022 (n = 2),^12,19 2023 (n = 3),^23,24,27 2024 (n = 1),¹¹ and 2025 (n = 6).^{1,14,15,17,21,31} (Figures 1 and 2) A timeline of key moments^26,32-35 in the reform of surgical training in Canada is represented in Figure 3.

Figure 1.

Number of Publications per Year.

Figure 2.

Number of Publications per Theme Per Year.

Figure 3.

Timeline of Key Events in the Reform of Surgical Training in Canada.

ROB Assessment

For the 16 observational studies evaluated with the NOS, 6 scored as low ROB.^14-16,19 However, 5 of these showed medium risk,^{14,15,19,27,28,30,31} and 3 were flagged for high risk.^2,12,22 Three additional observational studies were assessed using the MINORS tool, with 1¹⁷ rated high risk and 2^18,25 medium risk. One perspective article²³ was evaluated using GRADE and had high ROB. Five qualitative studies assessed with the Joanna Briggs Critical Appraisal tool all scored low risk.^{3,20,21,26,29} In total, 44.00% (n = 11) studies were low ROB, 36.00% (n = 9) were medium ROB, and 20.00% (n = 5) were high ROB (Table 2).

Table 2.

ROB Assessment.

Author, Year	1) Representativeness of the Exposed Cohorta) Truly Representative of the Average _______________ (describe) in the Community ̄ B) Somewhat Representative of the Average ______________ in the Community ̄ C) Selected Group of Users Eg Nurses, Volunteers D) No Description of the Derivation of the Cohort	2) Selection of the Non Exposed Cohorta) Drawn from the Same Community As the Exposed Cohort ̄ B) Drawn from A Different Source C) No Description of the Derivation of the Non Exposed Cohort	3) Ascertainment of Exposurea) Secure Record (eg Surgical Records) ̄ B) Structured Interview ̄ C) Written Self Report D) No Description	4) Demonstration That Outcome of Interest Was Not Present At Start of Studya) Yes ̄ B) No	Total Selection Stars	1) Comparability of Cohorts on the Basis of the Design Or Analysisa) Study Controls for _____________ (select the Most Important Factor) ̄b) Study Controls for Any Additional Factor ̄ (This Criteria Could Be Modified to Indicate Specific Control for A Second Important Factor.)	Total Comparability Stars	1) Assessment of Outcome A) Independent Blind Assessment ̄ B) Record Linkage ̄ C) Self Report D) No Description	2) Was Follow-Up Long Enough for Outcomes to Occura) Yes (select An Adequate Follow Up Period for Outcome of Interest) ̄ B) No	3) Adequacy of Follow Up of Cohortsa) Complete Follow Up - All Subjects Accounted for ̄ B) Subjects Lost to Follow Up Unlikely to Introduce Bias - Small Number Lost - > ____ % (select An Adequate %) Follow Up, Or Description Provided of Those Lost) ̄ C) Follow Up Rate < ____% (select An Adequate %) and No Description of Those Lost D) No Statement	Total Outcome Stars	Total Stars	Overall Risk
Observational Studies: NOS
Ying, 2023	a	a	a	a	4	a	1	b	a	b	3	8	Low
Maruscak, 2012	a	a	b	b	3	a, b	2	c	a	c	2	7	Low
Seemann, 2019	c	c	c	b	0	a	1	c	a	b	2	3	High
Brown, 2021	b	a	a	b	3	a, b	2	c	a	b	2	7	Low
Rajendran, 2022	a	c	a	a	3	c	0	c	a	b	2	5	Medium
Miazga, 2025	ba	c	a	b	2	c	0	c	a	a	2	4	Medium
Jiang, 2025	a	c	a	b	2	c	0	b	b	a	2	4	Medium
ElAbd, 2025	b	c	c	b	4	a, b	2	c	b	b	3	9	Low
ElHawary, 2023	b	c	c	b	1	a, b	2	c	a	a	1	4	Medium
Zhu, 2025	a	c	a	b	2	a, b	2	a	b	a	2	6	Medium
Akuffo-Addo, 2024	a	a	a	a	4	a, b	2	a	a	a	3	9	Low
Alam, 2022	b	c	c	b	1	a	1	c	b	b	0	2	High
Hours, 2013	a	c	a	b	1	a, b	2	d	b	d	0	3	High
Mocanu, 2020	a	a	b	a	4	a, b	2	c	a	b	2	8	Low
Urowitz, 2003	b	c	c	b	1	A, b	2	c	a	a	1	4	Medium
McInness, 2018	a	c	a	b	2	c	0	b	b	a	2	4	Medium

Observational Studies: MINORS
	1. Clearly Stated Aim	2. Inclusion of Consecutive Patients	3. Prospective Collection of Data	4. Endpoints Appropriate to Aim of Study	5. Unbiad Assessment of the Study Endpoint	6. Follow Up Period Appropriate to Aim of the Study	7. Loss to Follow Up <5%	8. Prospective Calculation of Study Size	9. Adequate Control Group	10. Contemporary Groups	11. Baseline Equivalence of Groups	12. Adequate Statistical Analyses
Author, Year	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	0 = not reported1 = reported by inadequate 2 = reported and adequate	Total Score
Mohajeri, 2025	1	1	1	1	0	1	1	0	NA	NA	NA	1	7	High
Patel, 2018	2	0	0	2	2	2	2	0	NA	NA	NA	2	12	Medium
Aminazadeh, 2012	2	0	0	2	2	2	2	0	NA	NA	NA	2	12	Medium

Perspective Article: Grading of Recommendations Assessment, Development and Evaluation (GRADE)
Author, Year	Study Design / Type	ROB	Inconsistency	Indirectness	Imprecision	Publication Bias	Overall Quality of Evidence	Risk of Bias
White, 2023	Expert opinion / narrative	Very serious	Not applicable	Serious	Serious	Possible	Very low	High

Qualitative Research: Joanna Briggs Institute (JBI) Critical Appraisal Checklist
	1. Was True Randomization Used for Assignment of Participants to Treatment Groups?	2. Was Allocation to Treatment Groups Concealed	3. Were Treatment Groups Simialr At Baseline	4 Were Participants Blind to Treatment Assignment?	5. Were Those Deliving Treatment Blind to Treatment Assignment?	6. Were Outcomes Assessors Blind to Treatment Assignment?	7. Were Treatment Groups Treated Identically Other Than the Intervention of Interest?	8. Was Follow Up Complete and If Not, Were Differences Between Groups in Terms of Their Follow Up Adequatetly Described and Analyzed?	9. Were Particiapnts Analyzed in the Group to Which They Were Randomized	10. Were Outcomes Measured in the Same Way for Treatment Groups?	11. Were Outcoems Measured in A Reliable Way?	12. Was Approraiate Statistical Analysis Used?	13. Was the Trial Design Appropraite and Any Deviations from the Standard Rct Design Accounted for in the Conduct and Analysis of the Trial?	Overall Analysis
Author, Year	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	0 NO1 Yes 2 Unclear 3 N/A	Total Score
Scallan, 2025	1	1	1	1	1	1	1	1	1	1	1	1	1	1	14 Low
Dussault, 2014	1	1	1	1	1	1	1	1	1	1	1	1	1	1	14 Low
Lie, 2021	1	1	1	1	1	0	0	1	1	1	1	1	1	1	12 Low
Romanchuk, 2004	1	1	0	1	1	0	1	1	1	1	1	1	1	1	12 Low
Sudarshan, 2012	1	1	1	1	1	1	1	1	1	1	1	1	1	1	14 Low

Discussion

Changing Definitions of Surgical Culture Training

Surgical culture encompasses the shared values, beliefs, and behaviors guiding how surgeons think, act, and interact, emphasizing technical excellence, resilience, hierarchy, and accountability. Historically, training stressed endurance, personal sacrifice, rigid hierarchies, and occasional arrogance,¹¹ but it is shifting toward collaboration, psychological safety, and coaching-based education.³⁶ In Canada, surgical culture increasingly emphasizes inclusivity, wellness, and holistic support, with yearly publications since 2017 and a peak in 2025. COVID-19 accelerated this shift: Among 122 residents, reduced in-person teaching and increased free time highlighted alternative educational approaches and resident well-being.¹² UBC's initiatives, including wellness programs, mandatory PPE training, and virtual teaching, emphasized community support.³

Gender and minority equity are gaining attention. Female residents still report stereotyping.¹³ Mocanu found 21% of female minority residents felt unsupported facing discrimination, versus 3% of male non-minority residents.¹⁶ Trends show gradual improvement: Ying observed rising completion rates among female trainees (2000–2010),²⁴ though ElHawary reported that 39% of female plastic surgery residents perceived gender-based disadvantage versus 3.6% of males despite identical case volumes.²⁷ This highlights a paradox: inequity perceptions persist even as measurable performance gaps narrow.

Psychological well-being is increasingly prioritized. At McGill, 75% of residents reported shaming, and 78% witnessed it,¹ yet awareness of its harm is shifting culture toward constructive, coaching-based feedback. Seemann noted that traditional expectations of emotional invulnerability limited discussion of stress, a barrier now addressed.²² Interventions like mindfulness-based cognitive therapy reduce anxiety, enhance confidence, and foster holistic professional development,¹⁵ while Patel highlighted residents’ awareness of cultural pressures to appear perpetually competent.¹⁸ Collectively, these trends indicate movement toward inclusivity, psychological safety, and emotional resilience.

Work-life integration and parental support also shape surgical culture. Jiang found that while all Canadian programs reported parental leave, only 35% mentioned lactation policies, and none covered fertility treatments.¹⁴ Scallan showed that maternity leave can enhance professional growth, improving communication, empathy, and confidence.²¹ Institutional support for family responsibilities thus benefits both well-being and professional competence.

Generational shifts and structural reforms further illustrate transformation. Contemporary residents report fewer planned workdays (7.4% vs 44.8% for faculty), reduced call frequency, and limited post-call duties, with female residents more likely to plan parental leave.⁴ Romanchuk described a shift from volume-based exposure to structured mentorship and competency-based evaluation,²⁰ while White emphasized differentiating competency from proficiency, prioritizing graduated autonomy and readiness for independent practice.²³ Together, these trends reflect a profession evolving toward wellness, equity, mentorship, and holistic professional development, redefining surgical excellence beyond endurance.

Duty-Hour Reforms

Canadian surgical training has evolved in duty-hour policies and resident wellness standards, reflecting a cultural shift toward sustainability and work-life integration. Historically, residents, especially interns, endured 24-h or continuous on-call schedules with minimal recovery, valuing endurance as commitment. In Quebec, consecutive call hours were reduced from 36 to 24 h in 1990 and to 16-h in-house calls by 2012 after legal challenges redefined acceptable working conditions.^2,26 These reforms influenced national policies, introducing limits on in-house and home call hours, mandatory post-call relief, and protected educational time, emphasizing structured learning and patient safety.²⁰ The 2018 Fatigue Management Toolkit further promoted strategies to reduce fatigue, optimize performance, and support well-being.³⁶

Medical residents are represented nationally by Provincial Housestaff Organizations such as (Ontario), Resident Doctors of BC (Alberta), and PARIM (Manitoba), collectively forming Resident Doctors of Canada. Quebec is unique with the Fédération des médecins résidents du Québec, a province-wide union under a single collective agreement securing strong protections, including 16-h call limits, guaranteed post-call leave, defined academic time, and robust parental and grievance policies. These reforms foster a fatigue-conscious, rights-driven training environment emphasizing resident well-being, safety, and learning quality.

Resident experiences reflect both traditional expectations and emerging norms. At McGill, 43% exceeded maximum call limits, and 36% reported institutional noncompliance1. Residents working over 80 h weekly had higher compassion fatigue,²² highlighting tensions between historic endurance models and modern priorities of safety, balance, and support. Positive experiences were linked to staff recognition of workload barriers.¹¹ While some residents and program directors remain hesitant about strict duty-hour limits,²⁸ competency-based cardiac surgery programs show autonomy and technical proficiency can be achieved without prolonged hours.^23,25 Senior residents are more likely than juniors to view duty-hour restrictions as hindering Royal College objectives,²⁹ reflecting ongoing negotiation between tradition and reform.

Parental leave illustrates this cultural evolution. Female residents average 36 weeks of leave versus 4 weeks for males.²⁷ National standards provide 17–52 weeks maternity and 24–72 weeks paternity leave, with paid leave in 82% of programs and salary supplementation of 84%–95%.¹⁴ Persistent barriers like scheduling, breastfeeding, and childcare are increasingly addressed, with phased return-to-work programs recommended.²¹ Residents now anticipate fewer workdays, reduced post-call duties, and a greater willingness to use parental leave.⁴ Structural supports, including equitable leave and accessible childcare, enhance retention and inclusivity, benefiting women and minority trainees.¹⁶

COVID-19 accelerated these changes. At UBC, rotations were reorganized, residents centralized, and a Resident Reserve Unit established.³ Virtual teaching and weekly town halls strengthened feedback and engagement. These adaptive strategies, combined with improved duty-hour policies, parental leave, mentorship, and union support, contributed to a decline in female surgical trainee attrition from 12.4% to 6.1% (2000–2010).²⁴ Overall, Canadian surgical education is shifting toward a sustainable, wellness-oriented, inclusive culture that balances training rigors with resident well-being and professional growth.

Wellness and Mental Health Initiatives

Wellness and mental health are central in Canadian surgical education, reflecting recognition of their impact on learning, performance, and retention. Despite growing research, gaps remain. Across 17 medical schools, trainees with darker skin reported isolation, microaggressions, and verbal abuse harming mental health, while female residents faced additional family-career balance challenges, worsened by poor work environments and sleep deprivation.¹¹ Gendered experiences intensify stress: at Calgary, 83% of women residents reported monthly gender-based discrimination versus 27% of men.¹³ Female plastic surgery and visible minority residents noted restricted surgical exposure, reduced collegiality, diminished belonging, and consideration of leaving residency.^16,27 However, emerging data suggest shaming and negative teaching, rather than gender alone, are stronger burnout predictors.¹

Structural factors strongly affect well-being. Excessive duty hours extended post-call work, and lack of protected rest reduce quality of life and learning.^2,26,28 Quebec's reduction of continuous on-call shifts from 36 to 16 h illustrates progressive wellness reform linking workload, fatigue, and patient safety.

Shame-based teaching, reported by 75% of residents, contributes to anxiety, isolation, and burnout, though higher grit and resilience improve coping.¹ COVID-19 highlighted wellness disparities: 41% reported increased anxiety, 61% heightened loneliness, and only 14% accessed institutional resources. UBC's Resident Reserve Unit introduced weekly town halls, virtual workouts, and meal support, fostering community and resilience.³ Residents also used personal coping strategies, including optimism (42%) and enjoyable activities (40%),²⁵ reflecting adaptive, self-sustaining approaches complementing institutional support.

Formal wellness initiatives now underpin surgical training, shifting from endurance-based education to holistic professional development. Mindfulness programs reduce anxiety and enhance confidence.¹⁵ Peer mentorship improves goal setting, work-life balance, and confidence.¹⁹ Tiered mentorship pairing junior residents with senior peers and faculty lowers stress, reducing Perceived Stress Scale scores from 18.5 to 6.8 and Maslach Burnout Inventory emotional exhaustion from 47.6 to 13.3. Work-hour restrictions and post-call relief improve fatigue, collegiality, and workplace civility,⁴ linking systemic reform with psychological well-being.

Parental leave and phased return-to-work policies further reflect cultural evolution. Canadian programs universally offer maternity, paternity, and adoption leave, with 82% paid, 71% lactation facilities, and 88% mental health coverage.¹⁴ Mentorship and peer support facilitate reintegration.²¹ Duty-hour reforms, including 1-in-4 in-house call and guaranteed post-call relief, balance workloads, protect study and technical practice time, and enhance both resident wellness and patient care.²⁰ Collectively, these initiatives promote psychological safety, resilience, and holistic professional growth, signaling a sustained cultural shift toward a healthier, supportive surgical training environment.

Equity, Diversity, and Inclusion

Equity, diversity, and inclusion (EDI) are central in Canadian surgical education, though disparities persist. By 2010, women made up nearly 40% of trainees, yet among 4891 academic surgeons, only 6% were women or people of color, compared with 56% White males.¹² These gaps reflect enduring intersectional barriers limiting access, mentorship, and advancement. Calls for structured national mentorship, holistic applicant review, and mandatory antiracism training aim to promote equity.¹¹ Yet women and gender minorities still face reduced operative autonomy, biased feedback, and systemic inequities.¹³ Female residents report restricted surgical exposure, gender-influenced career goals,²⁷ and continued experiences of shame-based learning,¹ showing cultural hierarchies still shape educational opportunities.

Female visible minority residents experience lower mentorship, support, and workplace belonging.¹⁶ Inconsistent parental leave policies continue to create barriers despite maternity, paternity, and adoption provisions.^3,4,14 Encouragingly, open dialogue, enhanced wellness benefits, and formal mentorship improve confidence, goal setting, and work-life balance,¹⁹ signaling early cultural shifts toward inclusivity. However, female residents remain hesitant to request lactation breaks or fear faculty disapproval,²¹ contributing to higher attrition than male peers (12.4% vs 6.1%).²⁴ Representation alone is insufficient, achieving equity requires structural, cultural, and behavioral change at institutional and national levels.

Inequities also extend to educational materials and structural supports. Darker skin tones are underrepresented in plastic surgery curricula, with only 16.8% of teaching images depicting Fitzpatrick IV-VI,³¹ limiting diagnostic exposure and cultural competence. International medical graduates report higher stress and fewer mentorship opportunities than Canadian-trained peers.²⁵ These findings emphasize that equity efforts must go beyond demographic representation to ensure inclusive curricula, equitable mentorship, and culturally competent teaching. Strengthening EDI across surgical education fosters a more supportive, representative, and high-performing learning environment, benefiting trainees and patients.

Feedback and Learning Environment

Feedback and the learning environment are pivotal for resident development, well-being, and professional identity. Historically, trainees lacked psychologically safe spaces, structured mentorship, and consistent advocacy, complicating navigation of surgical hierarchies. Honesty, confidentiality, and advocacy influenced learning more than racial or gender concordance,¹¹ yet trainees of color reported isolation, microaggressions, and limited mentorship.¹¹ Stressors like exams, competing clinical and academic demands, and extended duty hours despite formal limits further discouraged some from pursuing surgery.^11,25 Positive experiences arose when faculty acknowledged barriers and fostered collegiality,¹¹ signaling a shift toward supportive, psychologically safe environments.

Equity in feedback reflects evolving inclusivity. Female and visible minority residents often received subjective, personality-focused feedback and less mentorship, while structured peer mentorship improved confidence, performance, and work-life balance.^13,16,19 Resident engagement, not gender, predicted operative exposure, showing agency increasingly drives learning.²⁷ Despite formal maternity leave, women faced structural and interpersonal barriers, though many reported enhanced communication, empathy, and organizational skills, valued alongside technical mastery.^13,17,18,31

Shame-based learning persists, undermining safety, confidence, and contributing to burnout.¹ Residents sometimes avoided questions to appear competent.¹⁸ Interventions like the MiST mindfulness program improved operating room confidence, reduced anxiety, and promoted reflection and peer support.¹⁵

COVID-19 accelerated adaptability. Canadian residents faced training disruptions but benefited from flexible, self-directed learning and digital integration.¹² At UBC, rotation restructuring, Resident Reserve Units, and virtual sessions-maintained continuity while emphasizing wellness and communication.³

Inclusive learning is increasingly prioritized. Surgical curricula underrepresented medium and dark skin tones but growing diversity in teaching materials signals commitments to equity.³¹ Gender-conscious cultures improve retention and satisfaction, with rising female representation and declining attrition over the past decade.^24,31 Structured feedback and safe learning environments enhance skill development, confidence, and overall well-being.

Global Transferability

The transferability of Canadian surgical training findings is shaped by legal, cultural, and institutional contexts. Quebec's duty-hour reforms, driven by provincial labor laws and arbitration, illustrate how local factors limit broader applicability. Most other provinces cap shifts at 24 h with 2 h for handover.^26,36,37

Jurisdictional comparisons show wide variation. The U.S. ACGME prioritizes patient safety, New Zealand limited hours in 1985 to 72 weekly with rest between shifts and every second weekend off, and Australia allows longer shifts but generally aligns residents with the workforce.² Canada's province-led system complicates reforms, though Royal College accreditation standards provide national leverage.^2,38,39

Context-specific variation also affects workload and outcomes. Canadian residents often have more regulated duty hours than U.S. and E.U. peers,⁴ with lower female trainee attrition reported.²⁴ Skills-transfer courses and curriculum diversity remain institution-specific, requiring multi-site validation.^20,31 Even with Canada-wide standards, findings may resist cross-specialty transfer.^25,28,29

The transition to Competence by Design (CBD), the Royal College's competency-based framework, emphasizes observable skills, individualized progression, and continuous feedback. Structured Entrustable Professional Activities and workplace-based assessments enable advancement based on competence rather than fixed time, fostering accountability, transparency, and readiness for independent practice.

Complementing this, the Canadian Excellence in Residency Accreditation (CanERA) framework introduced standards emphasizing continuous quality improvement, learner experience, educational culture, and wellness, shifting evaluation from compliance-based to outcomes-based and promoting a coaching-oriented culture.

Together, CBD and CanERA have improved the quality, safety, and adaptability of Canadian surgical training.

Recommendations are shown in Supplemental Figure 3.

Future Directions

Future research should use longitudinal studies to evaluate how scheduling, simulation-based learning, and wellness initiatives affect resident competence, team communication, and patient outcomes. This includes expanding the Canadian consensus framework to examine the integration of fatigue management plans into training. Studies should also assess how leadership, institutional support, and resident empowerment influence the adoption of sustainable workload reforms. Additionally, Canadian research should evaluate the long-term impact of CBD training on operative proficiency, faculty engagement, and resident well-being to guide ongoing improvements in competency-based surgical education.

Conclusion

Canadian surgical training is evolving through duty-hour reforms, wellness programs, parental leave, and equity initiatives. Duty-hour and leave policies support balanced, sustainable training, while wellness programs address burnout, discrimination, and excessive workloads via mentorship, mindfulness, and psychological safety. Equity, diversity, and inclusion are increasingly prioritized. Structured feedback, competency-based training, mindfulness, and digital learning create safer, more supportive learning environments. Although transfer beyond Canada is limited, multi-site validation is valuable. Ongoing research, cross-provincial collaboration, and culturally responsive reforms are essential to sustain learner-centered training that balances education, well-being, and patient care.

Supplemental Material

sj-pdf-1-psg-10.1177_22925503261457119 - Supplemental material for From Tradition to Wellness: A Systematic Review of Changing the Surgical Training Culture in Canada

Supplemental material, sj-pdf-1-psg-10.1177_22925503261457119 for From Tradition to Wellness: A Systematic Review of Changing the Surgical Training Culture in Canada by Sara B. A. Morel, Rawan Elabd, Joshua Vorstenbosch, Dino Zammit, Gaby Doumit and Stephanie Thibaudeau in Plastic Surgery

Supplemental Material

sj-pdf-2-psg-10.1177_22925503261457119 - Supplemental material for From Tradition to Wellness: A Systematic Review of Changing the Surgical Training Culture in Canada

Supplemental material, sj-pdf-2-psg-10.1177_22925503261457119 for From Tradition to Wellness: A Systematic Review of Changing the Surgical Training Culture in Canada by Sara B. A. Morel, Rawan Elabd, Joshua Vorstenbosch, Dino Zammit, Gaby Doumit and Stephanie Thibaudeau in Plastic Surgery

Supplemental Material

sj-pdf-3-psg-10.1177_22925503261457119 - Supplemental material for From Tradition to Wellness: A Systematic Review of Changing the Surgical Training Culture in Canada

Supplemental material, sj-pdf-3-psg-10.1177_22925503261457119 for From Tradition to Wellness: A Systematic Review of Changing the Surgical Training Culture in Canada by Sara B. A. Morel, Rawan Elabd, Joshua Vorstenbosch, Dino Zammit, Gaby Doumit and Stephanie Thibaudeau in Plastic Surgery

Footnotes

ORCID iDs

Sara B. A. Morel

Rawan Elabd

Joshua Vorstenbosch

Author Contributions

Conceptualization: S.Morel, R.ElAbd, J.Vorstenbosch, D.Zammit, G.Doumit, S.Thibaudeau. Data curation: S.Morel, R.ElAbd. Formal analysis: S.Morel, R.ElAbd. Methodology: S.Morel, R.ElAbd, J.Vorstenbosch, D.Zammit, G.Doumit, S.Thibaudeau. Project administration: S.Morel, R.ElAbd. Supervision: R.ElAbd, J.Vorstenbosch, D.Zammit, G.Doumit, S.Thibaudeau. Validation: S.Morel, R.ElAbd, J.Vorstenbosch, D.Zammit, G.Doumit, S.Thibaudeau. Writing: Original draft: S.Morel, R.ElAbd. Writing: Review & editing: S.Morel, R.ElAbd, J.Vorstenbosch, D.Zammit, G.Doumit, S.Thibaudeau.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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