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When surgeons face intraoperative challenges: A naturalistic model of surgical decision making


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Background: Surgery is an environment in which being an expert requires the ability to manage the unexpected. This feature has necessitated a shift in surgical decision-making research. The present study explores the processes by which surgeons assess and respond to nonroutine challenges in the operating room. Methods: We used a grounded theory methodology supported on intraoperative observations and postoperative interviews with 7 faculty surgeons from various specialties. A total of 32 cases were purposively sampled to compile a dataset of challenging situations. Results: Thematic data analysis yielded 3 main themes that were linked in a cyclic model: assessing the situation, the reconciliation cycle, and implementing the planned course of action. These elements were connected through 2 points of transition (ie, active and confirmatory reconciliation), during which time the surgeons continue to act although they may change the course of their action. Conclusions: The proposed model builds on existing theories of naturalistic decision making from other high-stakes environments. This model elaborates on a theoretic language that accounts for the unique aspects of surgery, making it useful for teaching in the operating room.
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Association for Surgical Education
When surgeons face intraoperative challenges:
a naturalistic model of surgical decision making
Sayra M. Cristancho, Ph.D.
*, Meredith Vanstone, Ph.D.
, Lorelei Lingard, Ph.D.
Marie-Eve LeBel, M.D.
, Michael Ott, M.D.
Department of Surgery, Department of Medical Biophysics,
Department of Medicine, Centre for Education Research &
Innovation, Western University, London, ON, Canada
Decision making;
BACKGROUND: Surgery is an environment in which being an expert requires the ability to manage
the unexpected. This feature has necessitated a shift in surgical decision-making research. The present
study explores the processes by which surgeons assess and respond to nonroutine challenges in the
operating room.
METHODS: We used a grounded theory methodology supported on intraoperative observations and
postoperative interviews with 7 faculty surgeons from various specialties. A total of 32 cases were pur-
posively sampled to compile a dataset of challenging situations.
RESULTS: Thematic data analysis yielded 3 main themes that were linked in a cyclic model: asses-
sing the situation, the reconciliation cycle, and implementing the planned course of action. These
elements were connected through 2 points of transition (ie, active and confirmatory reconciliation),
during which time the surgeons continue to act although they may change the course of their action.
CONCLUSIONS: The proposed model builds on existing theories of naturalistic decision making
from other high-stakes environments. This model elaborates on a theoretic language that accounts
for the unique aspects of surgery, making it useful for teaching in the operating room.
Ó2013 Elsevier Inc. All rights reserved.
Surgery has grown increasingly complex in recent years,
becoming an environment in which being an expert is
characterized by an ability to manage the unexpected. This
evolution has created new opportunities to explore decision
making in surgery. Contemporary research has started to move
away from a focus on understanding routine problem-solving
patterns in the face of common problems
and toward a more
nuanced understanding of the dynamic process of decision
making in nonroutine situations in order to prepare surgeons
to meet uncertainty with flexibility and innovation.
The present study sought to further the understanding of
surgical decision making during challenging situations by
exploring the processes by which experts assess and
respond to nonroutine challenges. This understanding is
necessary to ensure that training and assessment respond to
the unique challenges of decision making during nonrou-
tine situations.
Research about intraoperative decision making has
traditionally followed 3 different approaches: (1) the feasi-
bility of deconstructing and explicitly identifying decision-
making tasks and influences for a given procedure,
(2) the
prevalence of ‘‘intuitive’’ and ‘‘analytic’’ decision-making
strategies faced by surgeons in challenging situations,
The authors declare no conflicts of interest.
* Corresponding author. Tel.: 11-519-661-2111 !89253; fax: 1519-
E-mail address:
Manuscript received April 9, 2012; revised manuscript September 4,
0002-9610/$ - see front matter Ó2013 Elsevier Inc. All rights reserved.
The American Journal of Surgery (2013) 205, 156-162
and (3) the cognitive shift that occurs when surgical experts
anticipate a challenging intraoperative situation.
following section reviews studies from each of the 3 aspects
in an attempt to describe the overall context in which the
present study is located.
A task deconstruction approach to decision-making ac-
tivities has been shown to be effective for training essential
decisions during laparoscopic surgery. Jacklin et al
a cognitive task analysis approach to deconstruct the standard
decision-making tasks associated with laparoscopic chole-
cystectomy. By interviewing surgeons about a hypothetic pa-
tient, Jacklin et al found that experienced surgeons
predominantly use 2 decision-making strategies when deal-
ing with routine decisions. For decisions involving a higher
degree of uncertainty (eg, deciding whether the patient
should be operated on or not according to the patient’s symp-
toms), surgeons relied more on their intuition and experience,
whereas for routine decisions related to implementing the
standard surgical technique (eg, deciding whether to use a
bag to extract the gallbladder or not), a rule-based approach
was more commonly used. Following a similar goal and us-
ing an observational approach, Sarker et al
proposed a
systems-based approach to task deconstruction that resulted
in a psychomotor surgical dynamic decision-making model.
Such a model constitutes a useful resource for scientists to
identify the situational elements at play when surgeons con-
front intraoperative decisions.
The process of understanding how surgeons implement a
decision in the operating room should involve a notion of the
types of isolated decision-making tasks as well as an under-
standing of the kinds of decision-making strategies. This
knowledge may be particularly helpful to surgeon-educators
as they work to develop the decision-making capacity of
surgical trainees and junior colleagues. Flin et al
and Pauley
et al
identified 2 prevalent types of decision-making strate-
gies used in surgery: intuitive and analytic. Using a naturalis-
tic approach, Flin and Pauley et al described surgical decision
making as a 2-stage process composed of situation assess-
ment and the selection of a decision strategy. Furthermore,
Flin et al
expanded on the latter element to describe 4
main decision strategies from the aviation literature (ie, intu-
itive, rule based, analytic, and creative) and the circumstances
in which they may be used in surgery. Using Flin et al’s model
in combination with the critical decision method, Pauley
et al
analyzed surgeons’ recall of surgical cases. They found
that intuitive thinking, (ie, a solution is quickly recalled from
a previous encounter with a similar situation) and analytic
thinking (ie, comparing between options) are the most prev-
alent strategies used to make intraoperative decisions during
both elective and emergency procedures. By including elec-
tive and emergency procedures, Flin et al’s work begins to
suggest that it may be important to differentiate between rou-
tine and challenging cases as suggested by a recent review.
One aspect of differentiating decision making between
routine and nonroutine moments during a procedure is the
way surgeons are able to anticipate that they are approaching
a challenging moment in the surgery. This cognitive shift has
been described by Moulton et al
as the ‘‘slowing down
when you should’’ phenomenon. Through the use of observa-
tional and interview data, Moulton’s model of surgical exper-
tise identifies 2 types of initiators for this transition:
proactively planned ‘‘slowing down’’ moments, which can
be predicted, and situationally responsive ‘‘slowing down’
moments, which are triggered by unexpected events and are
therefore unpredictable. Moulton et al’s contributions have
been pivotal in advancing the understanding of how a surgeon
recognizes the advent of an upcoming challenging moment.
In summary, previous research has established several
facts that further the understanding about surgical decision
making including the feasibility of deconstructing and
identifying decision-making tasks and influences, the prev-
alence of both intuitive and analytic strategies depending
on the decision-making context, and the existence of a
cognitive shift that takes place when surgeons anticipate an
intraoperative challenge. Our research seeks to complement
these important advances by addressing the ways in which a
surgeon creates an understanding of the situation and then
generates and implements a solution to the challenge,
particularly by describing the process of creating, choosing,
or adapting situationally responsive options.
A grounded theory methodology was used in support of
our goal of developing theory in an area about which little is
This approach
was selected because it affords a
means to explore how and why specific decisions were
made by the surgeons. As a qualitative research methodol-
ogy, the constructivist grounded theory allowed us to engage
in the exploration of the tacit knowledge that arises from the
surgeons’ reflections on their internal cognitive processes
about their approach to decision making in the operating
room. In this way, we were able to explore the nature of per-
ceived challenges as expressed by the participating surgeons
rather than dictating a particular definition of ‘‘challenge,
which may not reflect their experience or opinions.
Informed by the postobservation interview technique
critical decision method (CDM),
observational and inter-
view data were collected to capture moments of surgical
challenge for 32 surgical cases between May 2011 and Feb-
ruary 2012. This is a methodology prevalent in naturalistic
studies of expert decision making and used to gather retro-
spective accounts of challenging incidents.
Our work is guided by the overall qualitative research
aims to provide rich descriptions of a situation to contribute
to the theoretical understanding of a phenomenon or
With this aim in mind, we engaged in theoretical
sampling wherein data are collected and analyzed concur-
rently with new cases sampled to elaborate or fill gaps in
the evolving analysis.
S.M. Cristancho et al. When surgeons face intraoperative challenges 157
Participating surgeons were sampled purposively to in-
clude rich informants with a variety of levels of experience
(ie, 5 to 20 years) in a variety of surgical specialties
(ie, general surgery, orthopedic surgery, cardiac surgery
[2], urology, vascular surgery, and neurosurgery). A total of
32 cases were purposively sampled to compile a dataset of
challenging situations; participating surgeons preselected
cases and notified 1 of the authors (S.M.C.) when a case was
booked that they predicted would be challenging. ‘‘Intra-
operative challenges’’ were defined as situations that sur-
geons predicted would require important judgment calls
from their part to decide the proper course of an operation.
Other ‘‘challenging’’ factors such as poor teamwork, distrac-
tions, equipment failures, and so on were not included in
our definition of an ‘‘intraoperative challenging situation.
Data collection
Each case was observed by a nonsurgeon (S.M.C.) who
has a Ph.D. in engineering and postdoctoral training in
surgical education and is an experienced surgical observer
with 7 years of experience observing surgical cases in the
operating room and interviewing surgeons for research
purposes. Observational field notes were taken regarding
specific utterances from surgeons and other health care
professionals, general conversations in the operating room,
and actions and interactions between staff members relating
to the surgery. These field notes were used in combination
with a semistructured interview guide to tailor a specific
postsurgery interview with the surgeon of each observed
case. The purpose of the interview was to explore the
surgeon’s behaviors and reflections on dealing with chal-
lenging intraoperative moments. Interviews took place
immediately after each observed procedure.
This postobservation interview technique follows the
This technique was particularly effective in re-
sponse to the high-risk, high-complexity nature of the me-
dium to long surgical procedures (ie, 4 to 14 hours)
observed. During longer procedures, many challenging
and uncertain moments may occur, and the surgeon is
sometimes unable to describe all of them within the context
of the situation. Observation-informed probes allowed the
surgeon to expand and further reflect on the details of the
situation beyond what was described in the initial recalling
of the moment. Because field notes were used to inform the
postsurgery interview, only interview data were analyzed in
the CDM method.
Data analysis
Following grounded theory principles, data collection
and analysis proceeded iteratively to allow theoretical
sampling to saturation. Data collection continued until
theoretical saturation was reached (ie, when no new con-
ceptual insights were generated from additional data).
Constant comparative techniques for thematic coding
were used.
Thematic coding began with open coding,
capturing each instance of consideration and decision mak-
ing related to surgical challenges. Focused coding was then
performed to concentrate on intraoperative processes.
These codes were then grouped into broader yet still spe-
cific categories reflective of recursive themes. The entire re-
search team received these thematic categories and
definitions, discussed their resonance with the data, and
proceeded to independently create models using the cate-
gories that originated from the focused coding. The mem-
bers of the research team then met to compare the
models they independently created. This comparison served
to highlight differences and similarities between the
models, which were discussed and reconciled between the
entire research team. A model was decided on between
all team members, and the categories were refined as nec-
essary to reflect their role in the overall model. The data
were then recoded using these refined categories as a guide.
Discrepant instances were searched for and discussed be-
tween 2 members of the research team (S.M.C. and
M.V.). The revised model was returned to the entire team,
who discussed and agreed on its credibility and resonance
with the data and their personal experiences as surgeons.
Rigor was ensured by following established qualitative cri-
teria including independent scrutiny, member checking
through respondent feedback,
method and theory trian-
and the formation of an audit trail of the an-
alytic process.
Nonroutine decision making was observed at least once
in each of the purposively sampled cases. During inter-
views, surgeons were able to provide rich reflections of the
nuances surrounding those nonroutine decisions. Thematic
data analysis yielded 3 main themes that were linked in
a cyclic model of decision making during challenging
surgery. The model consists of 3 elements (ie, assessing the
situation, reconciliation cycle, and implementing the
planned course of action) and 2 points of transition during
which time the surgeons continue to act although they may
change the course of their action (Fig. 1).
The proposed model uses the premise, which was
commonly expressed by participants, that surgeons begin
each surgery with a planned course of action and continue
to revise that planned course of action throughout the
surgery in response to emerging information and the
perceived level of difficulty. We refer to the ‘‘planned
course of action’’ as any action that was created and
decided on before execution. Planned courses of action may
include the detailed preoperative plans designed for elective
procedures, the minimal plans created for emergency
procedures, and evolving intraoperative plans for each
small stage of the operation. The proposed model is framed
as a cycle through which surgeons may travel many times
over the course of a surgery, especially if that surgery is
158 The American Journal of Surgery, Vol 205, No 2, February 2013
challenging. The cycle may be traveled during each differ-
ent stage of the surgery or several times within the same
stage if challenges arise. A surgical ‘‘stage’’ is idiosyncrat-
ically defined by each surgeon and may be specific to the
procedure being performed.
Elements of the model
Although this model separates the steps of assessing,
reconciling, and implementing for purposes of clarity,
analysis indicates that these steps may often overlap; this
overlapping is reflected in the iterative transition phases.
The proposed model begins with a preoperative plan
formed before the surgeon enters the operating room and
informed by all the information available before the
surgery. For elective surgeries, this might include clinic
visits, imaging, the opinion of colleagues, and research the
surgeon has performed. For surgeons performing emer-
gency surgeries, less information may be available, but our
interviews indicate that a preoperative plan is still made and
that plan takes into consideration all the information
available at the time. As 1 participant explained about an
elective surgery, ‘‘I spent a lot of time reviewing the
imaging with the radiologist to ensure that what we were
planning to do was even technically possible.I talked to a
colleague who does the same kind of surgery as me and
suggested to them the approach I was planning to take and
said ‘can you look at the imaging and do you think it’s
reasonable what I’m planning to do?’’’ (case 27).
Assessing the situation. With the preoperative plan in
mind, the surgeon begins the surgery by assessing the situa-
tion, remaining alert for information that indicates potential
challenges to the preoperative plan. The assessment of the
situation also involves interpreting available information to
determine whether challenges anticipated in the previous
stage may arise or not or if there is any indication of
previously unanticipated challenges. Based on the inter-
pretation of intraoperative information and the comparison
with the existing planned course of action, the surgeon may
choose to adjust the current planned course of action,
moving into the reconciliation cycle to make this decision.
The following explanation shows how the planned course
of action may change once the intraoperative situation is
assessed, necessitating the creation of a new plan: ‘‘There
was a hernia around the colon and we were going to close
that defect in the muscle and then place a mesh around it,
but when we got there, there was no bridge in the muscle
where the colon came out and where the hernia was and
since there is no bridge and it was all a big hole, it just
seemed to make more sense to remake the stoma and then
reposition it rather than repair the old defect’’ (case 1).
Reconciliation cycle. The reconciliation cycle is charac-
terized as a continuous, iterative process of gaining infor-
mation; weighing the information found against what is
expected or typical and against the planned course of
action; and thinking ahead, projecting future steps of the
operation and again reconsidering the planned course of
action to determine if this is still the best way to proceed.
Gaining information. During surgery, information may be
gained through a variety of means. Sources of information
may include other people present in the operating room as
described by 1 participant, ‘‘There’s a fair bit of collective
experience in the room separate from me’’ (case 31), or
from nonhuman sources in the operating room (eg, ‘‘I know
from my previous experiences that I have to rely on the
fluoro a lot because I don’t see the fracture’’ [case 9]).
Information may be actively sought (eg, asking a question
of a colleague, ‘‘Dr. X had the ability to watch [the monitor]
Figure 1 A naturalistic model of intraoperative decision making.
S.M. Cristancho et al. When surgeons face intraoperative challenges 159
and assess, so he was in a better position to judge are we in a
good location, yes or no’’ [case 22]). Information may be
actively sought using visual or haptic senses to determine
anatomic information (eg, ‘‘We had to use special retraction
sutures to pull the fat away so that we could actually see [the
artery]’’ [case 30]). Information may also perceived without
active seeking through the process of monitoring conditions
in the operating room such as ‘‘you have to interpret all the
cues that the nurses are giving you and the perfusionist’
(case 28). Many surgeons spoke of the ways in which they
gained information they were not explicitly seeking by
remaining observant while acting (eg, by noticing anatomic
changes, ‘‘we saw inflammation between the pulmonary
artery and the aorta and that immediately told us we had to
slow down’’ [case 28]).
Weighing information. While conducting the surgery, the
surgeon receives a large amount of information and must
simultaneously interpret this information while acting and
deciding on future action. The surgeons might weigh new
information against other sources of information, past expe-
riences, and prior knowledge about this surgery obtained
earlier in the surgery or preoperatively as shown by the
following example: ‘‘I had doubts, based on all our imaging,
that we were going to be able to remove the tumor. Our
approach was just to kind of slowly work at the periphery to
the central part of it and just dig it piece by piece and bit by bit
until we could really make a judgement call as to whether it
was mobile enough to be removed or not’’ (case 20). While
receiving and interpreting this information, the surgeon is
also weighing that information against what the expected
findings were in order to determine whether the existing
course of action is still satisfactory. The surgeon may find
things as expected and choose to continue on with the
planned course of action (eg, ‘‘I knew that harvesting his
artery underneath the ribs was not going to be easy because
his chest was very barrel-chested and his lungs were smoker’s
lungs. We were confronted with challenges as expected.’
[case 10]). Alternatively, the surgeon may encounter some-
thing that was unexpected while planning this course of
action and decide to change the plan, ‘‘I opened [the left heart
artery] at the point where on the angiogram it predicted free
of disease. It was rock hard. I had to extend the opening
further distally, further beyond, to the second piece of vein to
that diseased artery’’ (case 30).
Projecting future steps. In this process of reconciling new
information with previous information and expected infor-
mation, the surgeon also anticipates future findings and
challenges, projecting a few steps further in the surgery to
anticipate possible challenges such as, ‘‘In an operation like
this I’m thinking a step or two ahead of what the steps are to
try and set up those steps as easily as possible’’ (case 29).
This process of projection is also reconciled with the
planned course of action to ensure that the current plan
remains satisfactory and that contingencies are considered if
unexpected information arises as shown by the following
quote: ‘‘I kind of have various options in my mind and I see
the patterns of what is available and what I have to work
with and just one of the options matches that pattern, so I
went with it’’ (case 1). The process of thinking ahead, or
projecting, may also include communication with the
surgical team to ensure that all members are prepared for
what may arise in the future as described by 1 participant,
‘Before I started I made sure that the nurses had some
stitches available that would be the appropriate stitches to
use to fix the hole I made if I made a hole’’ (case 20).
Throughout this process of the reconciliation cycle, new
information is compared with the original plan, and possi-
ble future findings are also compared with the existing plan
with adjustments made as needed. After the reconciliation
cycle, the surgeon may choose to proceed as planned, or the
surgeon may choose to alter or reprioritize the planned
courses of action.
Implementing. After confirming or revising the planned
course of action, the surgeon begins to implement the
planned course of action, again alert for possible challenges
throughout this implementation. During implementation,
there is an iterative movement between implementing the
planned course of action and reconciling new information
gained from each step with the planned course of action to
ensure that the plan remains satisfactory as the following
explanation describes: ‘‘It became very clear when we first
tried to do some of the maneuvers to mobilize the stomach
that the stomach wasn’t going to move and the tumor was
near the perforation so that option [initial plan] was not
even possible.
Transitional cycles of the model: active and
confirmatory reconciliation
The transition phases are called active reconciliation and
confirmatory reconciliation. Both phases represent iterative
movements of comparing new information with the planned
course of action in an attempt to ensure that the planned
course of action is satisfactory. The difference between
active and confirmatory reconciliation is that active recon-
ciliation occurs at the beginning of a new stage of the
surgery when new information is being uncovered and
the planned course of action is more likely to be changed.
The plan may be adjusted to ensure that it is technically
feasible, will have the best possible outcomes, has a
comfortable margin of safety, uses the available human
and equipment resources, and is consistent with what the
surgeon knows about the patient’s preferences. Confirma-
tory reconciliation occurs when a plan has been decided on
and is being implemented. New information may be
obtained during implementation, and the surgeon must
remain alert to this possibility and be prepared to adjust the
planned course of action to respond to this information in
order to ensure that the objective of that stage of the
operation is accomplished. When the surgeon is satisfied
with the implementation of the miniplan, 1 round of the
cycle is complete. The surgeon then transitions to the next
stage of the operation and begins the cycle again, assessing
160 The American Journal of Surgery, Vol 205, No 2, February 2013
the new situation and comparing it against the previously
formed miniplan, which takes the place of the preoperative
plan in subsequent iterations of the cycle. In this way, the
cycle repeats, with each stage informing the subsequent
stage. Both the overall plan for the operation and the
miniplans evolve as the procedure progresses.
We were able to observe and explore in interviews the
decision-making process of the experienced surgeons in the
face of nonroutine problems. Our results echo a process
approach to decision making in surgery, which is reflective
of the premises of the naturalistic decision-making research
Naturalistic decision making examines the
performance of expert practitioners during complex or
challenging situations, suggesting that experts seem to
take an ‘‘intuitive’’ approach to decision making when fac-
ing complex moments. This assertion contrasts with tradi-
tional notions of decision making as an educated choice
between multiple options.
Based on our observations and interviews, we propose a
model of intraoperative decision making that conceptualizes
this phenomenon as a continuous cycle. Elements of this
iterative cycle include defining what the problem is, under-
standing what a reasonable solution would look like, and
taking action to reach that goal and evaluating the effects of
that action.
This proposed model shares similarities with
Klein’s recognition model for decision making by expert fire-
but our model has been constructed to reflect im-
portant particularities of the surgical context. Klein’s
model based on research with firefighters
suggests that
firefighters used intuitive decision making, generating only
a single option instead of comparing 2 or more options. If
the course of action seemed appropriate (when mentally sim-
ulating the option), then the firefighters would implement
that option. If the first strategy was not sufficient, the fire-
fighters would try to modify their chosen option. Klein’s ap-
proach emphasizes decision processes (ie, characterizing
what firefighters actually do when making decisions) rather
than focusing on the catalysts of their decisions.
Although our model also emphasizes processes, it has
been adapted to the particular context of surgery, including
crucial differences such as (1) the presence of a preoperative
plan that is tailored to the specific situation; (2) moderate as
well as extreme time pressure, which allows surgeons to
engage in a conscious process of gaining and weighing
information; and (3) familiarity with both the physical
context and the team members before entering the situation
(ie, surgeons are familiar with the layout of the operating
room, they choose the equipment in advance, they may know
who will be the resident or the nurses for the day, and so on).
In view of this, our model characterizes intraoperative
decision making as a 3-element cycle with 2 associated
transitional processes: active reconciliation and confirma-
tory reconciliation. The connecting element in the model
guiding these transitions is the reconciliation cycle. The
reconciliation cycle in our model provides additional
granular details about the process that Klein describes in
his model
as mental simulation. Within our reconciliation
cycle, we have identified the sources (ie, human and nonhu-
man) and methods (ie, active information seeking, passive
information receiving, and information perceived in the
course of acting) by which surgeons gain information
from the environment to better conceptualize the problem
at hand. Future research will look more deeply at investi-
gating the ‘‘reconciliation’’ phenomenon by describing
how the surgeon’s knowledge and past experience are com-
bined with information received in the surgical environ-
ment to generate an understanding of the situation. One
interesting aspect to be considered while further investigat-
ing the ‘‘reconciliation’’ phenomenon is the potential differ-
ences between less and more experienced surgeons. This
will allow us to describe more fully the role of contextual
information in the surgeons’ decision-making activities in
the face of nonroutine problems.
Our work focuses on understanding the internal cogni-
tive processes that guide surgeons as individuals in making
decisions during challenging situations. This decision-
making process is a complex phenomenon with multiple
elements informing or affecting it. However, in order to
properly situate such elements within the phenomenon of
surgical decision making, it is important to first describe the
tacit knowledge and approaches that surgeons use individ-
ually as suggested by this study. As part of our program of
research, we are interested in applying a ‘‘systems’
approach to the study of decision making, and, therefore,
future work will build on our current model to progres-
sively incorporate aspects such as interactions with other
elements present in the operating room (eg, other team
members, assistive technology, and so on).
In relation to assessing decision-making skills, recent
research has generated a number of tools to code and
assess nontechnical skills in the operating room: Anesthetists
Non Technical Skills (ANTS) for anesthesia and Non Tech-
nical Skills for Surgeons (NOTSS), Non Technical Skills
(NOTECHS), and revised NOTECHs for surgeons.
though the purpose of these tools is to measure social and
cognitive skills during live
and simulated opera-
the assessment is based exclusively on observa-
tions, which makes it difficult to capture in detail the
phenomenon of surgical decision making as a process. The
following questions remain unanswered: What features in-
form the implementation and revision of decisions? and Do
those features present differently during routine surgical
cases vs emergency and complicated cases? One way to be-
gin answering these questions is by looking into how sur-
geons navigate the ‘‘reconciliation cycle’’ described in our
model. Features such as the type of information a trainee
looks for at a given difficult moment during the surgery and
the rationale behind the selection and use of such information
may help elaborate what surgical assessors are looking for
when they evaluate trainees’ cognitive skills. A recent sys-
tematic review has suggested that although most studies in
S.M. Cristancho et al. When surgeons face intraoperative challenges 161
the operating room have looked at routine elective proce-
dures, there may be fundamental differences in nonroutine
or challenging settings although this is unclear because of
the lack of empiric evidence in the literature.
By focusing
on challenging situations, our work may provide preliminary
insights into these issues.
The main limitations of this study include the recruit-
ment of surgeons from a single educational institution and
the reliance on participants’ assessment of anticipated
challenges for case selection and on 1 single observer.
Moreover, following the tenets of grounded theory re-
search, our sample of surgeons is small and purposefully
focused on experienced surgeons and intended for theory
building rather than generalization to the entire surgical
population. We aimed to guard against hindsight bias that
may be linked to the interview method of the CDM by
using the observation field notes to inform the postsurgery
interviews. Despite these limitations, our work responds to
recent claims in the literature for studies of nontechnical
skills in surgery that rely on empiric evidence.
Our study adds to the existing literature by providing a
model that characterizes the cognitive processes that sur-
geons engage in to assess and respond to intraoperative
challenges. Our model of intraoperative decision making is
derived from surgeons’ intraoperative behaviors and post-
operative reflections and builds on existing theories of
naturalistic decision making from other high-stakes envi-
ronments. This model also elaborates on a theoretical
language that accounts for the unique aspects of the surgical
environment. We anticipate that our model will be useful to
2 audiences: (1) decision-making scientists interested in
making explicit the tacit approaches to challenging situa-
tions that surgeons use in the operating room; and
(2) educators interested in making their decision-making
strategies visible as they interact with surgical trainees.
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162 The American Journal of Surgery, Vol 205, No 2, February 2013
... Surgeons should also carefully weigh potential risks and complications against the intended benefits of their intraoperative decisions. 6,7 In our bariatric unit, we perform LRYGB in antecolic fashion as standard practice or laparoscopic sleeve gastrectomy (LSG) when relevant. Our patients meet the national guidelines for bariatric or metabolic surgery. ...
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Background: Surgeons may encounter unexpected anatomical or pathological findings during various bariatric surgical procedures for which they must make prompt and critical decisions that had not been planned prior to the operation. In this practice review, we present our experiences with unexpected challenges and on-table decision making in bariatric surgery to share our knowledge with colleagues who may encounter the same challenges during bariatric surgery. This paper's content is of applied learning and practical value focusing on challenging intraoperative decision making; however, it does not discuss the details of the various techniques used during surgery. Methods: This work is a single-center retrospective review of operations carried out on patients who had unexpected intraoperative findings during bariatric surgery despite the implementation of detailed preoperative evaluations that would have otherwise suggested standard procedures. These findings resulted in abandoned surgery or laparoscopic sleeve gastrectomy instead of the intended Roux-en-Y gastric bypass. Results: A total of 449 patients had received various bariatric interventions in our unit between 2012 and 2016. Eleven patients, representing approximately 2.4% of the total number of patients surveyed had met the inclusion criteria and were added to the final list for analysis. The mean age of the included patients was 40.82 years (range: 30-51 years), and seven of the patients, representing approximately 63.6% of the included cases, were female. The mean body mass index of the 11 cases was 40.8 (range: 38-48). Only two cases (18.9%) had had their surgery abandoned; the rest (81.1%) had received laparoscopic sleeve gastrectomy instead of Roux-en-Y gastric bypass. None of the 11 patients had perioperative morbidity or mortality. Conclusion: Intraoperative decision making for unexpected findings in bariatric surgery is challenging. In these circumstances, surgeons must make prompt and critical decisions, including abandoning the operation. The available literature on this subject is unsurprisingly limited because of the rarity of such findings.
... Intraoperative decision making is a key component of all surgeons' work. [1][2][3][4] Making sound intraoperative decisions is critical to ensuring patient safety. 5,6 As such, it is essential that surgeons in training learn how to develop good intraoperative judgment in the operating room (OR). ...
Objective To explore how pediatric neurosurgeons train residents in developing intraoperative decision-making judgement. Design This study used the Grounded Theory Method in its study design. In-depth interviews were conducted with pediatric neurosurgeons about their approaches to training residents in intraoperative decision making. Data was analyzed line-by-line with codes and categories emerging from participants narratives. Setting & Participants Twenty-six pediatric neurosurgeons from 12 countries were interviewed using video-conferencing technology. Results Pediatric Neurosurgeons used a variety of training approaches that included pre-surgery discussions, didactic communication during surgery, post-surgery debriefing, allowing residents to model and observe their own intraoperative behaviors, using case studies to teach, and ongoing mentorship. In addition, they encouraged residents to ask for help when needed and emphasized the importance of empathy as a surgeon. Challenges to training residents included the notion that decision-making could only be learned through personal experience, the trainee's personality, and an over-reliance on algorithms and standardized medicine. Conclusions Training neurosurgical residents about intraoperative decision-making appears to be ad-hoc and dependent on both the institution and the availability and willingness of senior surgeons to make this a part of their pedagogy. Surgical departments could use these findings to reflect on their own teaching practices and explore whether they wish to teach these skills more explicitly, and in what ways these skills can be best taught to residents.
Introduction: Pediatric neurosurgery is a sub-specialty of medicine that is responsible for diagnosing, managing, and treating neurological disease in children with the use of surgery. Good intraoperative decisions making is critical to ensuring patient safety, yet almost nothing is known about what factors play a role in intraoperative decisions. As such, the purpose of this paper was to explore the factors that influence intraoperative decisions when pediatric neurosurgeons encounter something unexpected or uncertain during surgery. Methods: The study utilized the Grounded Theory method of data collection and analysis. Twenty-six pediatric neurosurgeons from 12 countries around the world were interviewed between June-October 2020 about the factors that go into making intraoperative decisions. Data was analyzed line by line and constant comparison was used to examine relationships within, and across codes and categories. Results: Pediatric neurosurgeons reflected on six factors while operating in order to come to a decision about how to proceed when they encountered an uncertainty or complication. The study findings resulted in a conceptual model that describes how concrete data including biological and technological factors and contextual data including emotional/relational factors, surgeon factors, and cultural factors influence risk assessment when making an intraoperative decision during surgery. Conclusions: The findings from this research can be used for training and educating surgeons about intraoperative decision-making processes. Pedagogical modules can be developed that includes training sessions on factors that may implicitly and explicitly influence thinking processes during an operation. Surgeons may also benefit from having open discussions with surgical colleagues about the rich, emotional, intellectual scope of the work that they do with all the challenges that these relationships can bring into decision-making in the operating room.
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La serie Teoría Educativa hecha Práctica tiene por objeto hacer que los fundamentos teóricos de la psicología educativa adquieran vida para el profesorado de profesionales de la salud, que deseen usar la teoría para informar su enseñanza en la clínica y el salón de clases. Originalmente escrito como un proyecto conjunto del blog Educador Clínico Internacional ( y el programa de Incubadora de Académicos La Vida Académica en Medicina de Emergencias (, este libro es un gran manual básico para quienes buscan aplicar la teoría educativa en su enseñanza cotidiana. La serie fue originalmente colocada como una serie de blogs y se sujetó a arbitraje abierto por pares. Este libro es un compendio editado de estos trabajos arbitrados, que han sido formateados y arreglados en formato de libro de texto.
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Purpose We evaluate the face, content, and construct validity of a portable hip arthroscopy module in a regional orthopaedic unit. Methods Participants were recruited from a regional orthopaedic centre, and categorized into novice (0 arthroscopies), intermediate (1-29 arthroscopies), and expert (>50 arthroscopies) groups based on reported experience in arthroscopy. Face and content validity was evaluated by feedback from users immediately following completion of modules. Objective measurements, including time taken and subjective measurements consisting of simulation software metrics including, cam lesion locations attempts, scope strikes on bone, healthy bone burred, and cam lesion burred. Scores achieved by experts were recorded, and the median score was set at the level at which proficiency was demonstrated. Participant feedback on perceived educational use was collected following completion. Results In total, 20 participant results were included for analysis. Good face and content validity was expressed by participants with previous arthroscopic experience. Number of scope strikes within the simulator-derived metrics accurately discerned between levels of experience. Novices had a mean of 5 strikes per attempt (SD ±5), intermediates a mean of 5.8 strikes (SD ± 4.1). There was a significant difference between expert and novice groups (P = .01), and expert and intermediate groups (P = .002). No significant difference between overall performance scores achieved by participants in expert, intermediate, and novice groups (62% ±19vs 55% ±22 vs 50% ±23,P = .15). This demonstrates incomplete construct validity of the simulator software-derived metrics. Conclusion This hip arthroscopy simulator demonstrated acceptable face and content validity, with incomplete construct validity of simulator software metrics. Participants reported high levels of satisfaction with the module, highlighting that the addition of haptic feedback would be beneficial to improve procedural steps. Incorporation of tactile feedback to the modulator components would likely enable the software to accurately delineate between levels of experience.
The importance of non-technical skills in surgery and robotics is becoming increasingly apparent. This has led to a growing focus on training and assessing these skill sets. Broadly, they are divided into cognitive (decision-making, situational awareness and planning) and social skills (teamwork, communication and leadership), alongside the personal resources factors an individual possesses. Some are particularly relevant to robotic procedures, including situational awareness and communication, due to the physcial distance present between the surgeon at the console, and the patient on the operating table. Training of these skills is predominantly undertaken in two settings: the classroom and the simulation lab. Teaching through didactic methods remains useful for introducing components of non-technical skills; however, it is often through simulation-based practice which allows for further more advanced development of these skills. Additionally, training of non-technical is increasingly being taught concurrently with technical skills, to reflect clinical practice. With increasing focus on training non-technical skills in robotic surgery, future work appears to be focusing on identifying the best modalities for training individual skill components such as leadership and decision-making. Furthermore, the use of cognitive training through mental imagery is being investigated as a cost-effective and self-directed modality to develop these skills in robotic procedures. It is therefore clear that whilst large strides have been achieved in robotic non-technical skills training, further work is still required to increase its wider scale incorporation and to identify the best modalities of training these unique skills.
Objectives Managing uncertainty is central to expert practice, yet how novice trainees navigate these moments is likely different than what has been described by experienced clinicians. Exploring trainees’ experiences with uncertainty could therefore help explicate the unique cues that they attend to, how they appraise their comfort in these moments, and how they enact responses within the affordances of their training environment. Methods Informed by constructivist grounded theory, we explored how novice emergency medicine trainees experienced and managed clinical uncertainty in practice. We used a critical incident technique to prompt participants to reflect on experiences with uncertainty immediately following a clinical shift, exploring the cues they attended to and the approaches they used to navigate these moments. Two investigators coded line‐by‐line using constant comparison, organizing the data into focused codes. The research team discussed the relationships between these codes and developed a set of themes that supported our efforts to theorize about the phenomenon. Results We enrolled 13 trainees in their first two years of postgraduate training across two institutions. They expressed uncertainty about the root causes of the patient problems they were facing and the potential management steps to take, but also expressed a pervasive sense of uncertainty about their own abilities and their appraisals of the situation. This, in turn, led to challenges with selecting, interpreting, and using the cues in their environment effectively. Participants invoked several approaches to combat this sense of uncertainty about themselves, rehearsing steps before a clinical encounter, checking their interpretations with others, and implicitly calibrating their appraisals to those of more experienced team members. Conclusions Trainees’ struggles with the legitimacy of their interpretations impact their experiences with uncertainty. Recognizing these ongoing struggles may enable supervisors and other team members to provide more effective scaffolding, validation, and calibration of clinical judgments and patient management.
Background: To advance orthopaedic surgical skills training and assessment, more rigorous and objective performance measures are needed. In hip fracture repair, the tip-apex distance is a commonly used summative performance metric with clear clinical relevance, but it does not capture the skill exercised during the process of achieving the final implant position. This study introduces and evaluates a novel Image-based Decision Error Analysis (IDEA) score that better captures performance during fluoroscopically-assisted wire navigation. Questions/purposes: (1) Can wire navigation skill be objectively measured from a sequence of fluoroscopic images? (2) Are skill behaviors observed in a simulated environment also exhibited in the operating room? Additionally, we sought to define an objective skill metric that demonstrates improvement associated with accumulated surgical experience. Methods: Performance was evaluated both on a hip fracture wire navigation simulator and in the operating room during actual fracture surgery. After examining fluoroscopic image sequences from 176 consecutive simulator trials (performed by 58 first-year orthopaedic residents) and 21 consecutive surgical procedures (performed by 19 different orthopaedic residents and one attending orthopaedic surgeon), three main categories of erroneous skill behavior were identified: off-target wire adjustments, out-of-plane wire adjustments, and off-target drilling. Skill behaviors were measured by comparing wire adjustments made between consecutive images against the goal of targeting the apex of the femoral head as part of our new IDEA scoring methodology. Decision error metrics (frequency, magnitude) were correlated with other measures (image count and tip-apex distance) to characterize factors related to surgical performance on both the simulator and in the operating room. An IDEA composite score integrating decision errors (off-target wire adjustments, out-of-plane wire adjustments, and off-target drilling) and the final tip-apex distance to produce a single metric of overall performance was created and compared with the number of hip wire navigation cases previously completed (such as surgeon experience levels). Results: The IDEA methodology objectively analyzed 37,000 images from the simulator and 688 images from the operating room. The number of decision errors (7 ± 5 in the operating room and 4 ± 3 on the simulator) correlated with fluoroscopic image count (33 ± 14 in the operating room and 20 ± 11 on the simulator) in both the simulator and operating room environments (R2 = 0.76; p < 0.001 and R2 = 0.71; p < 0.001, respectively). Decision error counts did not correlate with the tip-apex distance (16 ± 4 mm in the operating room and 12 ± 5 mm on the simulator) for either the simulator or the operating room (R2 = 0.08; p = 0.15 and R2 = 0.03; p = 0.47, respectively), indicating that the tip-apex distance is independent of decision errors. The IDEA composite score correlated with surgical experience (R2 = 0.66; p < 0.001). Conclusion: The fluoroscopic images obtained in the course of placing a guide wire contain a rich amount of information related to surgical skill. This points the way to an objective measure of skill that also has potential as an educational tool for residents. Future studies should expand this analysis to the wide variety of procedures that rely on fluoroscopic images. Clinical relevance: This study has shown how resident skill development can be objectively assessed from fluoroscopic image sequences. The IDEA scoring provides a basis for evaluating the competence of a resident. The score can be used to assess skill at key timepoints throughout residency, such as when rotating onto/off of a new surgical service and before performing certain procedures in the operating room, or as a tool for debriefing/providing feedback after a procedure is completed.
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Background The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery. Methods A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study. Results Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list. Conclusion Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.
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For the past 20 years, the democratization of additive manufacturing (AM) technologies has made many of us dream of: low cost, waste-free, and on-demand production of functional parts; fully customized tools; designs limited by imagination only, etc. As every patient is unique, the potential of AM for the medical field is thought to be considerable: AM would allow the division of dedicated patient-specific healthcare solutions entirely adapted to the patients’ clinical needs. Pertinently, this review offers an extensive overview of bone-related clinical applications of AM and ongoing research trends, from 3D anatomical models for patient and student education to ephemeral structures supporting and promoting bone regeneration. Today, AM has undoubtably improved patient care and should facilitate many more improvements in the near future. However, despite extensive research, AM-based strategies for bone regeneration remain the only bone-related field without compelling clinical proof of concept to date. This may be due to a lack of understanding of the biological mechanisms guiding and promoting bone formation and due to the traditional top-down strategies devised to solve clinical issues. Indeed, the integrated holistic approach recommended for the design of regenerative systems (i.e., fixation systems and scaffolds) has remained at the conceptual state. Challenged by these issues, a slower but incremental research dynamic has occurred for the last few years, and recent progress suggests notable improvement in the years to come, with in view the development of safe, robust and standardized patient-specific clinical solutions for the regeneration of large bone defects.
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The objective of this study was to examine the way decisions are made by highly proficient personnel, under conditions of extreme time pressure, and where the consequences of the decisions could affect lives and property. Fire Ground Commanders (FGCs), who are responsible for allocating personnel and resources at the scene of a fire, were studied using a critical incident protocol analysis. The major finding was that in less than 12% of the decision points was there any evidence of simultaneous comparisons and relative evaluation of two or more options. Instead the FGCs most commonly relied on their experience to directly identify the situation as typical and to identify a course of action as appropriate for that prototype. A Recognition Primed Decision (RPD) model is proposed which emphasizes the use of recognition rather than calculation or analysis for rapid decision making.
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When undertaking any research study, researchers must choose their sample carefully to minimise bias. This paper highlights why practitioners need to pay attention to issues of sampling when appraising research, and discusses sampling characteristics we should look for in quantitative and qualitative studies. Because of space restrictions, this editorial focuses on the randomised controlled trial (RCT) as an example of quantitative research, and grounded theory as an example of qualitative research. Although these 2 designs are used as examples, the general principles as outlined can be applied to all quantitative and qualitative research designs. Research studies usually focus on a defined group of people, such as ventilated patients or the parents of chronically ill children. The group of people in a study is referred to as the sample . Because it is too expensive and impractical to include the total population in a research study, the ideal study sample represents the total population from which the sample was drawn (eg, all ventilated patients or all parents of chronically ill children). This point—that studying an entire population is, in most cases, unnecessary—is the key to the theory of sampling . Sampling means simply studying a proportion of the population rather than the whole. The results of a study that has assembled its sample appropriately can be more confidently applied to the population from which the sample came. Using the examples of samples provided at the start of the paragraph, we can see that Chlan sampled 54 patients from a population of patients who required mechanical ventilation,1(see Evidence-Based Nursing 1999 April, p49) whereas Burke et al sampled 50 children (and their parents) from a population of all children requiring admission to hospital for chronic health conditions.2(see Evidence-Based Nursing 1998 July, p79) In both studies the researchers wanted to …
The grounded theory approach to doing qualitative research in nursing has become very popular in recent years. I confess to never really having understood Glaser and Strauss' original book: The Discovery of Grounded Theory. Since they wrote it, they have fallen out over what grounded theory might be and both produced their own versions of it. I welcomed, then, Kathy Charmaz's excellent and practical guide.
Surgical flow disruptions can significantly increase the probability of surgical errors. However, little is known about the frequency and nature of surgical flow disruptions, making the development of evidencebased interventions extremely difficult. The goal of this project was to prospectively study surgical errors and their relationship to surgical flow disruptions within the context of cardiac surgery. A trained observer recorded surgical errors and flow disruptions during 31 cardiac operations over a three-week period. Flow disruptions were then reviewed and analyzed by an interdisciplinary team of surgical and human factors experts. Results revealed that flow disruptions consisted of teamwork/communication failures, equipment and technology problems, extraneous interruptions, training-related distractions, and resource accessibility issues. Errors increased significantly with increases in flow disruptions. Teamwork/communication failures were the strongest predictor of surgical errors. These findings provide preliminary data for developing evidenced-based error management and patient safety programs within cardiac surgery.
The background of this article is the observation that the methodological discussions about qualitative research in German-speaking and Anglo-Saxon contexts are quite different, The article gives an overview of the state of the art of qualitative research in terms of its methodological development and its establishment in the broader field of social research. After some brief remarks about the history of the field, the major research perspectives and schools of qualitative research - grounded theory, ethnomethodology, narrative analysis, objective hermeneutics, life-world analysis, ethnography, cultural and gender studies - are outlined against the background of recent developments. The establishment of qualitative research is discussed with reference to the examples of the German and International Sociological Associations (DCS and ISA), to developments in the area of textbooks and handbooks, and to the founding of specialized journals. Methodological trends such as the move to visual and electronic data, triangulation of methods and the hybridization of qualitative procedures are discussed. In conclusion some perspectives are outlined which are expected to become more important in the future of qualitative research or which are seen as demands for further clarification. Beside the use of computers and further clarification on linking qualitative and quantitative research, and the limits and problems of such linkage, further suggestions concerning the ways of presenting appropriate and at the same time compulsory criteria for qualitative research an mentioned. Trends in building schools and developing research pragmatics, on the one hand, and a tendency towards elucidation and mystification of methodological procedures, on the other hand, are identified as tensional fields in methodological discussions in qualitative research.