Clinical surgery—International
Mapping surgical practice decision making: an interview study to evaluate decisions in surgical care

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Abstract

Background

Training surgeons in vital decision-making skills remains unstructured. We aimed to map a process of care from the perspective of surgical decision making and test whether it could be deconstructed into an accessible format for trainees.

Methods

Semistructured interviews were conducted with 10 experienced surgeons by using symptomatic gallstones as a clinical exemplar. Data were analyzed by 2 independent reviewers to identify decisions, cues, and decision rules, with further thematic analysis of selected decisions.

Results

Eighteen specific decisions were identified in 6 or more transcripts, with significant interreviewer reliability (Spearman's ρ = .65, P = .004, n = 17, 1 outlier excluded). These were arranged to form a “decision map.” Two main decision strategies were described.

Conclusions

We identified and mapped the decisions made in the care of patients with symptomatic gallstone disease. The interpretation of competency at any procedure should include the surgeon's ability to make appropriate decisions at all stages of patient care.

Section snippets

Aims

The first objective of this study was to map the process of care from the perspective of surgical decision making by identifying explicitly all the decisions in the care pathway of patients with symptomatic gallstone disease, which was used as a clinical exemplar. The second objective was to test whether the high-level, cognitive surgical skill of decision making can be deconstructed reliably into a conceptually accessible format for surgical trainees.

Design

We used interviews with a group of experienced surgeons to elicit the key decisions in the management of patients with symptomatic gallstones, our clinical exemplar. Qualitative research methods have provided a useful framework for addressing other behavioral research questions in surgery, such as communication in operating rooms.7 Interviews have also been used to elicit how expert clinicians' knowledge of particular clinical conditions is represented as sophisticated “illness scripts”.8

Participants

We

Results

In the first section of results, we present our findings regarding what decisions must be made by a surgeon treating a patient with symptomatic gallstone disease. In the second section, we discuss surgeons' decision strategies. We also discuss the only judgement of risk expressed quantitatively by surgeons, their estimation of the probability of conversion of a laparoscopic procedure to open.

Comments

The first aim of this study was to identify explicitly what decisions are made in the course of routine care of patients with symptomatic gallstone disease and to map the process of care from the perspective of surgical decision making. We think that the study accomplished this aim. Our analysis of interviews with 10 experienced surgeons identified 18 key decisions across the different phases of care (pre-, intra-, and post-operative) and across both elective treatment and emergency admission.

Acknowledgment

The authors would like to thank the Royal College of Surgeons of England for supporting this study via a research fellowship kindly provided by the Grand Lodge 250th Anniversary Fund and the Rosetrees Foundation, and also the British Academy for additional support.

References (17)

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