Background
The training of surgeons is undergoing a paradigm shift. Traditional apprenticeship models, rooted in time-based exposure and opportunistic learning, are increasingly viewed as insufficient for ensuring competence and expertise in a field where errors can have life-altering consequences. Deliberate Practice (DP), a pedagogical framework grounded in educational psychology, offers a compelling alternative by emphasising structured, feedback-driven, and goal-oriented practice. The application of DP principles in surgical education, however, particularly within simulation-based training, remains limited and poorly understood.

Aim
This study explores the role of DP in developing Expert Performance in surgery and investigates the barriers to its implementation in surgical training programs.

Methods
The first phase involved a systematic review of the literature assessing the extent to which Simulation-Based Surgical Training (SBST) interventions adhered to key DP principles—namely, learner motivation, structured task design, timely feedback, and repetition—and evaluating their outcomes. A scoring rubric was developed to assess DP adherence across studies.
The mixed-methods phase included self-administered questionnaires and semi-structured interviews with surgical trainees and trainers to explore their perceptions of DP and identify practical, cultural, and systemic barriers to its implementation. Data were analysed using thematic analysis and integrated with quantitative findings to understand the current landscape comprehensively.

Results
The systematic reviews identified multiple papers on open and laparoscopic surgery, most of which reported positive outcomes associated with simulation-based interventions. Only a minority of studies, however, fully incorporated all core elements of DP. Interventions with higher DP adherence scores demonstrated more consistent improvements in skill acquisition, retention, and transferability. Most studies assessed outcomes at Kirkpatrick levels 1 and 2, with limited evidence of behavioural or patient-level impact.
The qualitative phase involved self-administered questionnaires and 20 semi-structured interviews with surgical trainees and trainers. Thematic analysis revealed four major themes: (1) Value of Structured Practice, (2) Feedback and Faculty Engagement, (3) Institutional Constraints, and (4) Educational Culture. Trainees reported that while simulation was widely appreciated, access to structured, deliberate practice opportunities was inconsistent and often self-directed. Trainers expressed willingness to engage in DP-aligned instruction but cited lack of time, inadequate institutional recognition, and limited pedagogical training as key barriers.
Both groups identified a misalignment between educational aspirations and clinical service demands. The lack of protected time for practice, the absence of standardised curricula incorporating DP principles, and insufficient assessment tools to measure progression were cited as systemic barriers to meaningful implementation. Despite these challenges, there was strong consensus on the transformative potential of DP when applied effectively within simulation-based surgical training environments.
Qualitative findings also revealed widespread awareness of the benefits of structured, repetitive practice and expert feedback among both trainees and trainers. Barriers to DP implementation included a lack of protected time, limited faculty availability, underdeveloped curricula, and institutional emphasis on service delivery over education. Participants also highlighted the absence of clear performance benchmarks and insufficient training in feedback provision as additional obstacles.

Conclusion
DP offers a powerful model for optimising surgical education. While evidence supports its effectiveness in simulation-based contexts, current implementation is limited by structural and pedagogical barriers. This study highlights the need for a deliberate and theory-informed redesign of surgical training that prioritises competence, safety, and the pursuit of expert performance.