Thinking like an expert: surgical decision making as a cyclical process of being aware

Cristancho, Sayra; Apramian, Tavis; Vanstone, Meredith; Lingard, Lorelei; Ott, Michael; Forbes, Thomas L.; Novick, Richard J.

doi:10.1016/j.amjsurg.2015.03.010

Cited by 34 publications

(29 citation statements)

References 28 publications

(43 reference statements)

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“…6 Sayra et al proposed the concept of reconcilation cycle, which constituted the iterative process of gaining and transforming information. 7 They observed that the cyclical nature of a surgeon's decision making implied that a higher degree of awareness was needed for transforming information. The factors governing these decisions, although interesting, is poorly understood.…”

Section: Discussionmentioning

confidence: 99%

An assessment of the factors affecting surgical decision making: a multi institutional study

Anandan

Sivakumar

2020

Int Surg J

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Background: Decision making is a complex process, especially when guidelines are lacking. Surgeons then turn to other factors to help guide them make these decisions. This study is an attempt to understand these factors which play a role in the decision making process of surgeons.Methods: A prospective qualitative study was conducted amongst consultant surgeons and surgical residents from various institutes across Bangalore. The questionnaire was sent out to these surgeons and responses were recorded using Google Forms. A total of 158 responses were received and analyzed.Results: 69.2% of surgeons felt that patient preferences influence their decision making process. Age of the patient and medical comorbidities played a role in the decision making process of 95.5% and 94.2% of the surgeons respectively. 91% of the surgeons agreed that their age and experience has a strong influence on the decisions made by them. The institution of work and availability of tools mattered to 61.7% and 80.1% of the surgeons respectively.Conclusions: Factors such as patients’ age, comorbidities, preferences, surgeon’s institution of study, institution of work, experience, and institutional factors influence the decisions made by surgeons. Further study is needed on the larger scale to fully understand the various factors playing a role in the final decision making process.

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Section: Discussionmentioning

confidence: 99%

An assessment of the factors affecting surgical decision making: a multi institutional study

Anandan

Sivakumar

2020

Int Surg J

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“…As a result, these questions always seem to be calibrated at the task level, the most elementary component of a surgical procedure. A task consists of three stages that must be performed by the surgical trainee: the motor action that transforms the patient's anatomy; an evaluation of its effect, and the selection of the next motor action . Collections of such tasks define a particular part or step in the surgical procedure.…”

Section: Discussionmentioning

confidence: 99%

“…A task consists of three stages that must be performed by the surgical trainee: the motor action that transforms the patient's anatomy; an evaluation of its effect, and the selection of the next motor action. [34][35][36] Collections of such tasks define a particular part or step in the surgical procedure. In total hip replacement surgery, the procedure of choice in this study, surgical trainees carry out 44 different steps between the incision of the skin and the final suture, each varying in complexity.…”

Section: And Nowmentioning

confidence: 99%

Recruiting expertise: how surgical trainees engage supervisors for learning in the operating room

et al. 2019

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Context For centuries now, the operating room (OR) has been the environment in which surgical trainees come to master procedures. Restricted working hours and insufficient levels of autonomy at the end of their training necessitate a shift towards alternative effective learning strategies. Self‐regulated learning is a promising strategy by which surgical trainees can learn more with fewer exposures. However, the challenge is to understand how surgical trainees regulate their learning in the clinical context of the OR. Objectives The purpose of this study is to identify and understand the strategies of surgical trainees in engaging their supervisors for learning purposes and how these strategies contribute to effective learning. Methods Total hip replacement procedures performed by four surgical trainees and their supervisors were videotaped. Using the iterative inductive process of conversation analysis, each verbal initiative to engage the supervisor was identified, analysed (‘why that now’) and categorised. Results Surgical trainees used a range of practices to engage supervisors and recruit expertise, ranging from explicit recruitment to implicit hints. We identified four major categories. Surgical trainees: (i) invite the supervisor to provide an evaluation of the ongoing task; (ii) express an evaluation of the ongoing task and then explicitly invite the supervisor to provide an evaluation; (iii) express an evaluation of the ongoing task and then invite the supervisor to provide confirmation, and (iv) express an evaluation of the ongoing task without engaging the supervisor. Conclusions Surgical trainees recruit expertise from supervisors using practices of four different categories. Trainees’ actions are provoked by the moment at which they experience insufficient expertise and are focused on the task at hand in the immediate present. Supervisors can and do elaborate on these requests to provide explicit teaching. Insight into these practices provides tools for reflection on OR learning, proficiency assessment and deliberation to adapt guidance in the real time of the procedure.

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“…Additional research from Cristancho et al (22), on how expert cognition develops found that those clinicians with less experience focused on information at a physiological or pathophysiological level, in contrast to experts who subconsciously focused on "the bigger picture," more readily putting new data into the clinical context. Our study did not demonstrate a significant evolution of analytical-tointuitive processes with increasing experience; however, this may be due to a lack of awareness amongst the respondents on the subtleties of their decision-making processes (23).…”

Section: Intuitive and Analytical Decision-making Is Positively Assocmentioning

confidence: 99%

Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors

Pumphrey

Grenville²,

Colquhoun

et al. 2019

Postgraduate Medical Journal

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PurposeTo identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade.Study designWe conducted a cross-sectional survey of doctors of different specialities and grades at St. George’s Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative.ResultsWe found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005).ConclusionsDecision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.

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Thinking like an expert: surgical decision making as a cyclical process of being aware

Cited by 34 publications

References 28 publications

An assessment of the factors affecting surgical decision making: a multi institutional study

An assessment of the factors affecting surgical decision making: a multi institutional study

Recruiting expertise: how surgical trainees engage supervisors for learning in the operating room

Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors

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