Tuesday, March 1, 2016



          In January 2016, Dr. Cristancho and the University of Calgary group published yet another excellent analysis attempting to explain how we perform surgical decision making in the midst of intraoperative challenges. If you have ever interviewed an expert in a high pressure field, then you can understand the immense challenge faced in interviewing a surgeon to tease out their thinking processes. In my experience, it can sometimes be a bit frustrating to ask experts in high pressure fields how they synthesize information during a period of challenge. I recently asked Colt McCoy (the past UT Quarterback now with the Redskins) that question and he explained that he is able to analyze the field and determine where the receivers and defenders are simultaneously without being distracted by years of training......... I am hoping to dig a bit deeper. I asked Rorke Denver (Navy Seal commander) the same question and he explained that they tried to escape whenever their psychologists came to ask them that same question and that they succeed thru vigorous training. I asked Tom Kolditz, Patrick Sweeney, Mike Mathews, Dave Grossman and a slew of others, what military experts say about responding to pressure and they all say the same thing - it's tough to tease information from these experts. So kudos to Cristancho for getting surgeons to stop and discuss these intimate processes, because I feel pretty certain it was not without some reservation. In turn, anyone who has read Malcolm Gladwell's BLINK, will remember that not only is it tough for an expert to explain in detail how they accomplish an amazing feat, but often they really off track and it turns out they did not know for certain but were guessing.

         In their 2013 study the Canadian group covered the difference between decision making in the way surgeons anticipate challenging moments during routine and non-routine moments. In non-routine situations, three stages of action are performed: situational assessment, reconciliation stage (where one gathers information and analyzes it) and planning/implementation phase. This is not dissimilar to the model I have presented in the past whereby successful crisis leaders utilize information from past experience, preimplementation planning and pattern recognition / avoidance of cognitive bias to understand when something wrong has occurred, pause, brief the team, gather information, prognosticate, plan, enact a single plan and then reassess. Poor commanders frequently attempt to shortcut this process and fail because they reacted too quickly or were impeded by anxiety or they stalled at an early phase and do not activate a plan of action.

          In their 2016 paper, the team explained that experienced surgeons revealed that they not uncommonly need to simultaneously deliver a quick response (damage control) while they are gathering information about the unexpected event (i.e. Damage control while inventorying resources and damage extent). In my experience, more often than not, surgeons state they have to REACT immediately and do not have the time or have any need to address the team so appropriate planning occurs- but clearly successful surgeons survive by doing just that. In this recent paper they also discovered that the process of gaining information is not that simple but entails actively seeking the information they discovered was absent and perceiving that information is lacking without actually knowing that for certain they were missing data (sounds confusing at first but makes sense when you think about it).   Also after interviews they found that their processes of weighing information and projecting were too simple and that a complex process they called transforming information occurs whereby the information that is gained by active seeking or perceiving is worked thru with a purpose. How you do that is dependent on whether you are a novice or an expert. Novices tend to focus on immediate and basic information and consequences while experts look beyond that information for patterns and decide how that affects the immediate and long term consequences (the bigger picture).

      All of this information beged the asking of a few questions: is this team developing training methods for teaching novice or poorly responding surgeons how to succeed based on gaining this information? Are they able to correlate response completeness to outcomes? Are they analyzing stress response in those who exemplify these decision processes compared to those who bypass those methods? Do they plan to measure or have they measured response times to compare to one being an “expert” vs a “novice”? Hopefully the authors will talk with me.


Fortunately, Dr Cristancho was kind enough to chat with me regarding their research in surgical decision making.

She brought up some points that I have been passionate about for quite a while. One question was: how do we really know we are teaching residents appropriately about responding to a challenge if we don't know how those who are successful at it manage to succeed? And the other was: how can we really understand the entire process and therefore teach it if we don't break it down to understandable steps that can be passed along?

Their work was designed to understand what experienced surgeons think they do, but was not aimed at validating if that was precisely what they did in these circumstances (i.e. Video) or what their stress responses were to their proposed reactions, or how effective they were in reaching a successful intervention to the challenge or teamwork, etc. This does however, give us a starting point to move towards those areas of research. She kindly sent me several other studies in this area which I am reviewing currently.  This led me to my next quest.....speaking with Gary Klein one of the gurus in Natural Decision Making, or the process of decision making during complex situations (Lt Gen Paul van Riper and Lygia Stewart recommended I talk with him).

Kenneth A. Lipshy, MD, FACS

  • Cristancho SM, Apramian T, Vanstone M, Lingard L, Ott M, Forbes T, Novick R.
    Thinking like an expert: surgical decision making as a cyclical process of being aware. Am Journal Surgery 2016. 211(1):64–69.
  • Cristancho S, Apramian T, Vanstone M, Lingard L, Ott M, Novick R.
    Understanding Clinical Uncertainty: What Is Going on When Experienced Surgeons Are Not Sure What to Do? Academic Medicine 2013. 88(10)1516–1521.
  • Cristancho S, Vanstone M, Lingard L, LeBel M, Ott M. When surgeons face intraoperative challenges: a naturalistic model of surgical decision making. Am Journal of Surgery 2013. 205(2):156–162.

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