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Non-physicianclinicians, suchas clinical officers andnurses, are trained to performspecific surgical
procedures,suchascesareansectionsandappendectomies.
Training Programs: To ensure the quality of care, task-shifting must be accompanied by
comprehensivetrainingprogramsandongoingsupervision.InitiativesliketheWorldHealth
Organization(WHO)’sSurgicalCare at theDistrict Hospital(SCDH) manual provide
standardized guidelines for training non-physician clinicians to safely perform surgical
procedures.
QualityandSafety:Whiletask-shiftingcanincreaseaccesstosurgicalcare,italsoraises
concerns about patient safety and outcomes. Careful monitoring and evaluation of taskshiftingprogramsareessentialtoensurethatthecareprovidedmeetsacceptablestandards
ofqualityandsafety.
17.1.3.3TelemedicineandRemoteConsultation
Advancesintelemedicinehaveenabledsurgeonsinhigh-incomecountriestoprovideremoteconsultation
andmentorshiptohealthcareworkersinlow-resourcesettings.Throughvideoconferencing,surgeonscan
offerreal-timeguidanceduringsurgicalproceduresorprovidediagnosticsupportforcomplexcases.
Benefits:Telemedicinehelpstobridgethegapbetweenlimitedlocalexpertiseandtheneed
for specialized surgical care. It also provides opportunities for knowledge sharing and
continuingeducationforhealthcareworkersinLMICs.
17.1.3.4GlobalSurgeryTrainingandPartnerships
Several organizations and academic institutions have establishedglobal surgery trainingprograms and
partnershipswithhospitalsinLMICs.Theseinitiativesaimtobuildlocalcapacitybyprovidingsurgical
training,resources,andmentorshiptohealthcareworkersinunderservedregions.
CaseExample: TheHarvardProgram inGlobalSurgeryandSocialChange (PGSSC)
works with local partners in LMICs to improve access to surgical care. Through these
partnerships, surgeons from HICs provide training and support to local surgical teams,
helpingtobuildsustainablesurgicalcapacity.
17.2GlobalHealthInitiativesandSurgery
Surgical care is increasingly being recognized as an integral component of global health, alongside
initiatives focused on infectious diseases, maternal and child health, and non-communicable diseases.
International organizations, governments, and non-governmental organizations (NGOs) are working to
addresstheglobalsurgerycrisisthroughadvocacy,funding,andpolicydevelopment.
17.2.1TheLancetCommissiononGlobalSurgery
In2015,theLancetCommissiononGlobalSurgerypublishedalandmarkreporthighlightingthecritical
needforsurgicalcareinglobalhealth.Thecommission’sfindingsunderscoredthefactthatsurgeryisan
essentialcomponentofhealthcare,andwithoutit,globalhealthgoalscannotbeachieved.
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17.2.1.1KeyFindings
TheLancetCommissiononGlobalSurgeryreportrevealedseveralkeyfindings:
SurgicalInequities:Morethan5billionpeopleworldwidelackaccesstosafe,affordable,
andtimelysurgicalcare.ThevastmajorityofthesepeopleliveinLMICs.
SurgicalWorkforceShortages:Anadditional143millionsurgicalproceduresareneeded
eachyeartomeettheunmetsurgicalneedsoftheglobalpopulation.
EconomicImpact: Investingin surgical care can have significanteconomic benefits.The
commissionestimatedthattheglobaleconomycouldloseupto$12.3trillioninproductivity
by2030duetothelackofaccesstosurgicalcare.
17.2.1.2GlobalSurgeryIndicators
Toguideprogressinimprovingaccesstosurgicalcare,theLancetCommissionidentifiedsixcoreglobal
surgeryindicators:
1. AccesstoTimelySurgery:Theproportionofthepopulationthatcanaccesssurgerywithin
twohoursofneedingit.
2. Surgical Workforce Density: The number of trained surgeons, anesthetists, and
obstetriciansper100,000people.
3. SurgicalVolume:Thenumberofsurgeriesperformedannuallyper100,000people.
4. Perioperative Mortality Rate: The percentage of patients who die within 30 days of
undergoingsurgery.
5. ProtectionAgainstCatastrophicExpenditure:Theproportionofthepopulationprotected
againstthefinancialburdenofsurgicalcosts.
6. Protection Against Impoverishing Expenditure: The proportion of the population
protectedagainstfallingintopovertyduetosurgicalcosts.
Theseindicatorsprovideaframeworkformeasuringprogressinglobalsurgeryandensuringthatefforts
toimprovesurgicalcarearetargetedandeffective.
17.2.2WHOInitiativesinGlobalSurgery
TheWorld HealthOrganization (WHO) has also played a critical role in advancing global surgery
throughitsGlobalInitiative for Emergency andEssentialSurgical Care (GIEESC). This initiative
focusesonimprovingaccesstoessentialsurgicalservicesinLMICsbypromotingtraining,research,and
policydevelopment.
Surgical Workforce Development: The WHO works with governments and healthcare
institutionsinLMICstostrengthensurgicaltrainingprogramsandimprovethedistributionof
thesurgicalworkforce.
Policy Advocacy: The WHO advocates for the integration of surgical care into national
health plans and budgets, emphasizing the importance of surgical services in achieving
universalhealthcoverage(UHC).
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17.3EthicsofHumanitarianSurgery
Humanitariansurgeryinvolves providingsurgical care in response to crises such as natural disasters,
armedconflicts,andchronichealthcaredisparities.Whilethegoalistosavelivesandreducesuffering,
humanitariansurgeryalsopresentsuniqueethicalchallengesthatmustbecarefullynavigated.
17.3.1EthicalPrinciplesinHumanitarianWork
Humanitarianworkisguidedbyseveralcoreethicalprinciples,including:
Humanity: The primary goal of humanitarian work is to alleviate human suffering and
protectlifeandhealth.
Neutrality: Humanitarian organizations must remain neutral in conflicts, providing care
basedonneedalone,withouttakingsides.
Impartiality: Care should be provided without discrimination, and patients should be
treated based on their medical needs, regardless of their political, religious, or ethnic
affiliations.
Independence:Humanitarianorganizationsmustbefreefromexternalpoliticalormilitary
influences,allowingthemtooperatebasedontheirethicalprinciples.
17.3.2ChallengesinDeliveringHumanitarianSurgicalCare
Deliveringsurgicalcareinhumanitariansettingsisfraughtwithchallenges,includinglimitedresources,
securityrisks,andethicaldilemmas.Someofthekeychallengesinclude:
17.3.2.1ResourceAllocation
In resource-constrained settings, humanitarian surgeons often face difficult decisions about how to
allocatelimitedresources.Thiscanincludechoosingwhichpatientstoprioritizeforsurgery,astheremay
notbeenoughsupplies,operatingrooms,orpersonneltotreateveryoneinneed.
Triage:Triagesystemsareusedtoprioritizepatientsbasedontheurgencyoftheircondition
and the likelihood of a successful outcome. However, making these decisions can be
emotionallyandethicallychallenging,particularlyinsituationswherelivesareatstake.
17.3.2.2QualityofCarevs.Access
Humanitarian surgeons must balance the need to provide high-quality care with the reality of limited
resources.Insomecases,thismaymeanprovidingsuboptimalcareinordertotreatmorepatients,rather
thanfocusingonfewerpatientswithmorecomprehensivecare.
EthicalDilemmas: This trade-off can lead to ethical dilemmas, as surgeons must decide
whethertofocusonsavingas manylivesaspossible or onprovidingthehighestpossible
standardofcaretoasmallernumberofpatients.
17.3.2.3SecurityandSafety
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Humanitariansurgeons oftenwork in conflictzonesor areas affected by natural disasters, where their
safetyandsecurityareatrisk.Ensuringthesafetyofhealthcareworkersisessential,butitcanbedifficult
tostrikeabalancebetweendeliveringcareandprotectingthelivesofthesurgicalteam.
AttacksonHealthcareWorkers:Insomeconflictzones,healthcareworkersandfacilities
are targetedbyarmed groups, making it dangerous to provide care. Despite international
agreementssuchas theGenevaConventions,attacksonmedical personnelareapersistent
probleminmanyconflictareas.
17.3.3CulturalSensitivityandPatientAutonomy
Inhumanitariansettings,culturalsensitivityiscriticaltoprovidingethicalcare.Surgeonsmustbeaware
ofthecultural,religious,andsocialnormsofthecommunitiestheyserve,andtheymustrespectpatients'
autonomyinmakingdecisionsabouttheircare.
Informed Consent: In resource-poor settings, obtaining informed consent can be
challenging, particularly when language barriers or limited health literacy are factors.
Surgeons must ensure that patients and their families understand the risksand benefits of
surgeryandhavetheopportunitytomakeinformeddecisions.
Respect for Local Practices: Humanitarian organizations must be respectful of local
customs and practices, while also advocating for the best possible medical care. This
requires open communication and collaboration with local healthcare providers and
communityleaders.
Conclusion
Globalsurgeryandhumanitarianworkrepresentsomeofthemostchallengingandrewardingaspectsof
modern medicine. Theneed for surgical care inlow-resource settings is immense, andaddressingthis
need requires a combination of innovative solutions, international collaboration, anda commitmentto
ethicalprinciples.
As global health initiatives continue to evolve, surgery is becoming increasingly recognized as an
essentialcomponentofhealthcare,rather thana luxuryreserved for those inhigh-incomecountries. By
improvingaccesstosafe,affordable,andtimelysurgicalcare,wecanmakesignificantstridesinreducing
theglobalburdenofsurgicaldiseaseandimprovinghealthoutcomesformillionsofpeopleworldwide.
Humanitariansurgery,whilefraughtwithchallenges,offersanopportunitytoprovidelife-savingcareto
those in the most desperate situations. However, it also requires careful consideration of the ethical
dilemmasthatariseinresource-constrainedandconflict-affectedenvironments.
The future of global surgery will depend on continued advocacy, investment in surgical training and
infrastructure,andacommitmenttotheprinciplesofequity,ethics,andhumanity.Throughtheseefforts,
wecanworktowardaworldwherenoonediesorsuffersneedlesslyfromalackofaccesstoessential
surgicalcare.
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CHAPTEREIGHTEEN
SurgicalEducationandTraining
The landscape of surgical education and training is ever-evolving to meet the increasing demands of
modernhealthcare.Surgicalprofessionalsareexpectedtobehighlyskilledintheirclinicalexpertiseand
innovative in adopting new surgical technologies and methods. This chapter focuses on the essential
aspectsofsurgicaleducation,includingresidencyandfellowshipprograms,continuingmedicaleducation
(CME), andtheimportanceof mentorshipandprofessional developmentinshapingsuccessfulsurgical
careers.
18.1ResidencyandFellowshipPrograms
Residency and fellowship programs are crucial stages in the development of surgeons, transforming
medicalgraduatesintospecialistsequippedwiththetechnical,clinical,andinterpersonalskillsnecessary
to perform complex surgical procedures. These programs provide structured, hands-on learning
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experiencesinbothclinicalandacademicsettings.
18.1.1StructureandDurationofResidencyPrograms
A surgical residency is typicallya multi-year program designedto provide comprehensive training in
generalsurgery,followed byspecializedtraininginsubspecialties ifdesired.Mostresidencyprograms
rangefromfivetosevenyears,dependingonthecountryandspecialty.Thestructureoftheseprograms
generallyfollowsatieredapproach:
Internship(PGY-1):Thefirstyearofresidency,oftenreferredtoastheinternship,provides
broad exposure to surgical practice. Residents rotate through various surgical services,
gainingexperienceinpreoperativeassessment,basicsurgicaltechniques,andpostoperative
care.Thisyearalso involvesworkingcloselywithseniorresidentsandattendingsurgeons
todevelopclinicaljudgment.
JuniorResidency(PGY-2to PGY-3): During thejunior residencyyears, traineestakeon
moreresponsibilities, includingperformingsurgeriesunder supervision,managingpatients
intheclinic,andparticipatinginresearch.Theseyearsfocusondevelopingtechnicalskills,
criticalthinking,anddecision-makingintheoperatingroom.
SeniorResidency(PGY-4toPGY-5/6):Seniorresidentsoftenleadsurgicalteams,making
decisions in the operating room and teaching junior residents. By this stage, they are
expected to be highly proficient in various surgical procedures and have significant
autonomyinpatientcare.
18.1.2FellowshipPrograms
Fellowshipprogramsprovideadditionaltraininginaspecificsubspecialtyaftercompletingaresidency.
Fellowships are designed to develop advancedsurgical skills and expertise infocused areas, such as
cardiothoracicsurgery,traumasurgery,pediatricsurgery,oroncologicsurgery.Theseprogramstypically
lastonetothreeyears,dependingonthesubspecialty.
18.1.2.1CommonSurgicalFellowshipSpecialties
Cardiothoracic Surgery: Focuses on surgeries related to the heart, lungs, and other
structuresinthechest.Cardiothoracicfellowsgainexpertiseinproceduressuchascoronary
arterybypassgrafting(CABG),heartvalverepairs,andlungresections.
Neurosurgery: Neurosurgery fellowships offer specialized trainingin treating conditions
affectingthebrain,spine,andnervoussystem.Fellowsperform complexsurgeriessuchas
craniotomies,spinalfusions,andbraintumorresections.
Trauma Surgery and Critical Care: This fellowship provides specialized training in
managing critically injured patients, including those with polytrauma, burns, and severe
chest and abdominal injuries. Trauma surgeons must be adept at handling emergency
laparotomies,thoracotomies,anddamagecontrolsurgeries.
Pediatric Surgery: Pediatric surgery fellowships focus on the surgical care of infants,
children, and adolescents. Fellows develop expertise in managing congenital anomalies,
pediatrictumors,andminimallyinvasivesurgeriesinchildren.
SurgicalOncology:Thisfellowshipemphasizesthesurgicaltreatmentofcancer,including
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tumor resections, lymph node dissections, and palliative surgeries. Surgical oncologists
workcloselywithoncologistsandradiologiststoprovidemultidisciplinarycancercare.
18.1.3SelectionandCompetencyEvaluation
The selectionprocess for surgical residency and fellowship programs is highlycompetitive, requiring
candidates to demonstrateacademic excellence, clinical experience, and a commitment to the field of
surgery.Onceadmitted,residentsandfellowsarerigorouslyevaluatedontheirtechnicalskills,clinical
decision-making,professionalism,andabilitytoworkaspartofateam.
18.1.3.1AssessmentMethods
Direct Observation: Attending surgeons observe residents and fellows during surgeries,
providing feedback on their technical skills, intraoperative decision-making, and
communicationwiththesurgicalteam.
Objective Structured Clinical Examination (OSCE): OSCEs are used to assess a
resident’sclinicalcompetenciesthroughstandardizedpatientencounters,testingtheirability
todiagnose,plantreatment,andcommunicateeffectivelywithpatients.
CaseLogsandPortfolios:Residentsarerequiredtomaintaindetailedlogsofthesurgical
procedures they have performed or assisted in. This documentation allows for the
assessmentofsurgicalvolumeanddiversityofcasesencountered.
Simulation Training: High-fidelity simulators are increasingly being used in surgical
training to assess residents’ technical skills anddecision-making abilities in a controlled
environment. Simulation-based assessments are particularly useful for evaluating
competencyinrareorcomplexprocedures.
18.1.4GlobalVariationinSurgicalResidencyTraining
Surgical residency programs vary widely across countries due to differences in healthcare systems,
regulatorybodies,andeducationalphilosophies.Somecountries,suchastheUnitedStates,Canada,and
Australia, havewell-structured, competency-based programs thatemphasize both clinical andresearch
training.Incontrast,otherregionsmayhaveshorteror less formalizedresidencystructures, whichcan
posechallengesforensuringconsistencyinthequalityofsurgicaleducation.
U.S.andCanada:ResidencyprogramsintheU.S.andCanadafollowastrictcompetencybased model, with trainees progressing through increasingly complex clinical
responsibilities. TheAccreditationCouncilforGraduateMedical Education(ACGME)in
the U.S. and theRoyal College of Physicians andSurgeons in Canada regulateresidency
standardsandensureconsistentevaluationofresidents.
Europe:InEurope,surgicalresidencyprogramsareregulatedbynationalmedicalboards,
and the duration and structure of training can vary. The European Union of Medical
Specialists (UEMS) provides guidelines for harmonizing surgical education across EU
countries.
Low-Resource Settings: In low-resource settings, surgical training programs may face
challengesrelatedtolimitedaccesstoteachinghospitals,facultyshortages,andinadequate
infrastructure. International partnerships and exchange programs are essential for
strengtheningsurgicaleducationintheseregions.
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18.2ContinuingMedicalEducation(CME)forSurgeons
Continuingmedical education(CME) isa critical componentofmaintainingandenhancinga surgeon’s
knowledge,skills,andprofessionaldevelopmentthroughouttheircareer.CMEensuresthatsurgeonsstay
up-to-date with the latest advancements in surgical techniques, technologies, and evidence-based
practices.
18.2.1TheImportanceofLifelongLearninginSurgery
The field ofsurgeryis dynamic, with constant innovations in surgical procedures, minimallyinvasive
techniques,androboticsurgery,aswell as evolvingstandards forpatientsafetyandqualitycare. CME
allows surgeonsto staycurrentwiththese changes, ensuring that they continue to provide high-quality
caretotheirpatients.
TechnologicalAdvancements:Advancesinsurgicaltechnology,suchaslaparoscopicand
roboticsurgery,requiresurgeonstocontinuallyupdatetheirtechnicalskills.CMEprograms
thatfocusonhands-ontrainingandsimulation-based learningare essential forsurgeonsto
masterthesetechnologies.
Evidence-Based Medicine: Surgical practice is increasingly driven by evidence-based
guidelines and clinical research. CME programs that emphasize critical appraisal of the
literatureandincorporationofresearchfindingsinto clinical practice help surgeonsmake
informeddecisionsaboutpatientcare.
18.2.2CMEFormatsandDeliveryMethods
CME can take many forms, ranging from formal courses and workshops to self-directed learning
activities. The format of CME programs has evolved over time, incorporating technology to make
learningmoreaccessibleandflexibleforbusysurgeons.
18.2.2.1TraditionalCMEActivities
Conferences andWorkshops: Professionalsurgical organizations, suchas the American
College ofSurgeons(ACS)andtheRoyalCollegeofSurgeons,hostannualconferences
and workshops that provide opportunities for surgeons to learn about new surgical
techniques,presentresearch,andengageinhands-onskillstraining.
Hands-OnTraining:Surgicalskillsworkshops,oftenheldincollaborationwithacademic
institutionsor hospitals,offer opportunities forsurgeons topractice newtechniquesunder
theguidanceofexperiencedinstructors.Theseworkshopsmayfocusonspecificareas,such
asadvancedlaparoscopicprocedures,endoscopy,orroboticsurgery.
18.2.2.2OnlineCMEandE-LearningPlatforms
Webinars and Virtual Conferences: Advances in digital technology have enabled the
development of online CME platforms, offering surgeons the flexibility to participate in
educationalactivitiesremotely.Webinars,virtualsurgicalconferences,andinteractivecase
discussionsarepopularformatsforonlineCME.
Mobile Applications: Mobile appsdedicated tosurgicaleducationprovide surgeonswith
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quick access to educational content, including videos of surgical procedures, clinical
guidelines, and case-based learning modules. These tools allow surgeons to engage in
learningonthego.
Simulation-BasedLearning:Virtualreality(VR)andaugmentedreality(AR)technologies
are increasingly being used for CME in surgery. These technologies allow surgeons to
practice complex procedures in a simulated environment, helping them improve their
technicalskillswithouttherisksassociatedwithrealpatientcare.
18.2.3AccreditationandCertificationofCMEPrograms
CMEprogramsmustbeaccreditedtoensurethattheymeethigheducationalstandards.Inmanycountries,
surgeons are required to complete a certain number of CME credits each year to maintain their
professionallicensureorboardcertification.
Accrediting Bodies: Organizations such as the Accreditation Council for Continuing
MedicalEducation (ACCME) inthe U.S.andthe European Accreditation Council for
ContinuingMedicalEducation(EACCME)inEuropeplayakeyroleinaccreditingCME
activitiesandensuringtheireducationalquality.
Certificationof CME Credits: Surgeons mustprovide evidenceoftheir participation in
accreditedCMEprogramstorenewtheirmedicallicenses or maintainboardcertification.
This certification process ensures that surgeons engage in continuous learning and
professionaldevelopment.
18.2.4BarrierstoAccessingCME
DespitetheavailabilityofCMEprograms,thereareseveralbarriersthatmaypreventsurgeonsfromfully
engagingincontinuingeducation:
TimeConstraints: Surgeons often havedemandingclinical schedules, whichcanmakeit
difficult to find time for CME activities, particularly in the case of long conferences or
workshopsthatrequiretravel.
Cost: CMEprograms,especiallythoseinvolvinghands-ontrainingorattendanceatmajor
conferences,canbeexpensive.Thisfinancialburdencanbeabarrierforsurgeonsworking
inlow-resourcesettingsorthoseintheearlystagesoftheircareers.
AccessinLow-ResourceSettings:Inlow-resourcesettings,accesstoCMEmaybelimited
by geographic isolation, lack of infrastructure, and financial constraints. International
collaborationsandonlineCMEplatformscanhelpbridgethisgap,offeringmoreequitable
accesstoeducation.
18.3MentorshipandProfessionalDevelopment
Mentorshipplaysapivotal roleintheprofessional developmentofsurgeons,helpingthem navigatethe
challenges of surgical training, build clinical and academic skills, and achieve career success.
Mentorship provides surgeons with guidance, support, and opportunities for growth throughout their
careers.
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18.3.1TheRoleofMentorshipinSurgicalTraining
Duringresidencyandfellowship,mentorshipiscriticalinshapingtheclinical,technical,andprofessional
skills ofsurgical trainees. Mentors provide personalizedguidance,helpingtrainees develop boththeir
surgicalexpertiseandtheirprofessionalidentity.
18.3.1.1TypesofMentorship
ClinicalMentorship:Inclinicalmentorship,seniorsurgeonsguidetraineesthroughpatient
care, helping them refine their diagnostic and decision-making skills. Mentors provide
feedbackonsurgicaltechniques,patientmanagement,andteamworkintheoperatingroom.
Academic Mentorship: For surgeons pursuing academic careers, mentorship in research
andteachingisinvaluable.Academicmentorshelptraineesdesignresearchprojects,write
grantproposals,publishpapers,anddevelopteachingskills.
Career Mentorship: Career mentors help trainees navigate their career paths, providing
advice on fellowship opportunities, job applications, work-life balance, and long-term
career goals. Mentors may also provide networking opportunities, introducing trainees to
influentialfiguresinthefield.
18.3.2BuildingEffectiveMentorshipRelationships
A successful mentorship relationship is built on trust, mutual respect, and clear communication. Both
mentorsandmenteesmustbecommittedtotherelationship,investingtimeandefforttoensureitssuccess.
18.3.2.1ResponsibilitiesofMentors
Providing Guidance: Mentors must offer constructive feedback and guidance on both
clinicalandprofessionalmatters,helpingmenteesnavigatechallengesandbuildconfidence
intheirskills.
Role Modeling: Mentors serve as role models, demonstrating the highest standards of
professionalism,ethics,andpatientcare.Menteeslooktotheirmentorsforexamplesofhow
tobalanceclinicalexcellencewithcompassion,integrity,andteamwork.
Advocacy: Mentors should advocate for their mentees, helping them secure fellowship
positions, research opportunities, or academic appointments. Mentors can also serve as
referencesforjobapplicationsorcareeradvancements.
18.3.2.2ResponsibilitiesofMentees
Active Participation: Mentees must be active participants in the mentorship relationship,
seekingoutopportunitiesforfeedbackandgrowth.Theyshouldbeproactiveindiscussing
theirgoals,challenges,andaspirationswiththeirmentors.
ReceptivenesstoFeedback:Menteesmustbeopentoconstructivecriticismandwillingto
learn from their mentors’ experiences. This requires humility and a commitment to
continuousimprovement.
Professionalism: Mentees should demonstrate professionalism in all aspects of their
training, including punctuality, communication, and respect for their mentors’ time and
expertise.
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