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
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
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-
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,
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: Sayra.Cristancho@schulich.uwo.ca
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
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
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
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
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
, 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.’’
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.
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
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-
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
Transitional cycles of the model: active and
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
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
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
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.
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