Graduate medical education unfolds in high-stakes clinical environments where residents function as both learners and frontline providers. In surgery, rising case volume, staffing shortages, and rapid expansion of advanced practice provider (APP) roles have intensified longstanding tensions between education and service. Although APPs are essential to continuity and efficiency, their integration has often outpaced the development of shared expectations and competency-based frameworks.The result is role ambiguity-most visible during periods of workload surge-regarding who should absorb excess demand. Unclear responsibility for "picking up the slack" disrupts teamwork, redistributes learning opportunities, increases cognitive load, and contributes to burnout among both residents and APPs. These effects are amplified by short resident rotations, APP continuity, and the absence of formal mechanisms to guide workload redistribution.Using a systems engineering lens, this perspective reframes slack absorption as a structural design problem rather than an individual failing, and identifies system-level opportunities to strengthen teamwork, protect educational integrity, and advance clinician well-being and patient safety.
Keywords: Advanced practice providers; Graduate medical education; Interprofessional teamwork; Role ambiguity; Surgical training; Systems engineering.
Copyright © 2026 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.