Abstract
The path through a graduate medical education training program is nuanced and complex. It is no wonder that some surgical residency and fellowship trainees struggle to keep up with expectations. When trainees do falter, in surgical training programs and others, their underperformance inevitably calls our attention to the trainee. We offer an expanded perspective that acknowledges the impact of often invisible systems on the trajectory of a trainee's performance. We show how the use of a systems-level view of a surgical trainee's professional development expands the range of interventions to rescue an underperforming trainee. Our proposed model shows a system characterized by balancing feedback loops and reinforcing feedback loops, which represent critical leverage points for altering an underperforming trainee's trajectory. A focus on feedback systems structures enables leaders (such as program directors and faculty mentors) to consider how small changes at the opportune times can lead to profound differences and help recognize system contributions essential for success. In this way, surgical training program leaders can change the trajectory of a young career that lasts far beyond the finite nature of surgical training.