Clinical science
Surgeons' intraoperative decision making and risk management

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Abstract

Background

Surgical research on decision making and risk management usually focuses on perioperative care, despite the magnitude and frequency of intraoperative risks. The aim of this study was to examine surgeons' intraoperative decisions and risk management strategies to explore differences in cognitive processes.

Method

Critical decision method interviews were conducted with 24 consultant surgeons who recalled cases and selected important decisions during the operations. These decision were then discussed in detail in relation to decision-making style and risk management.

Results

The key decision in each case was made using either a rapid, intuitive mode (46%) or a more deliberate comparison of alternative courses of action (50%). Decision strategy was not related to surgical approach (endoscopic vs open), context (elective vs emergency), perceived time pressure, or situational threats. Risk management involved perceiving threats and assessing impact but also indicated the role of personal risk tolerance.

Conclusions

Surgeons described making key intraoperative decisions using either an intuitive or an analytic mode of thinking. Surgeons' risk assessment, risk tolerance, and decision strategies appear to be influenced by their personalities.

Section snippets

Participants

Consultant (attending) surgeons (n = 24) from 3 teaching hospitals in Scotland were invited to participate via e-mail from a senior surgical colleague. The surgeons (21 men, 3 women), aged 35 to 62 years (mean age, 47 ± 7 years), had an average of 10 ± 8 years of experience as attending or consultant surgeons (range, .5–28 years). The specialties included general, orthopedic, vascular, transplant, and urologic surgery.

Procedure

Surgeons were randomly allocated to recall a case from 1 of 4 categories of

Results

The 12 emergency and 12 elective procedures discussed are shown in Table 1. Of the emergency operations, 2 involved trauma patients. Intraoperative decisions and the management of intraoperative risks are discussed in turn.

Comments

Surgeons described key decisions taken using either the rapid, intuitive RPD mode, matching a response to the situation, or a more deliberate comparison of alternative courses of action (labeled analytic).

As suggested by Abernathy and Hamm,18 preference of decision-making strategy may relate more to personal style than to the type of operation (endoscopic or open), context (emergency or elective surgery), the existence of perceived time pressure, or the level of complexity of the situation and

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    This work is supported by funding from the Scottish Funding Council (Scottish Patient Safety Research Network).

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