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Internal motivation is a prerequisite for learning but cannot be relied on as the sole driving source for a successful training program. Surgical residents and practicing surgeons are affected by long working hours, limited free time, and seemingly endless clinical responsibilities. Not surprisingly, studies on voluntary participation of skills training in a busy residency showed the participation rate as between 6 and 14% [41, 43]. Also, 82% of ACVS residents reported that lack of time was the main barrier to practice [15].

These studies showed that providing dedicated regular time for mandatory training, known ahead of time to trainees and their faculty, greatly improved participation. For a laboratory with limited resources, this may be hard to accomplish. In the VALT laboratory, we have had success with mandatory training sessions but with timing flexibility through an online sign‐up policy, so each trainee can choose the time that works best for him or her without affecting the clinic or crowding the laboratory. The importance of dedicated laboratory personnel, keeping track of the trainees' sessions, and the commitment from faculty in supporting the training cannot be stressed enough. In addition, external motivation can be gained from training feedback and scheduled skills assessments. Further external motivation may be gained by performance requirements on simulators before OR participation [41], Importantly, we have found an inverse relationship between motivation for simulation training and clinical experience [7], regardless of skill level, underscoring the importance of initiating simulation training early in a laparoscopic surgeon's career.