DECISION
MAKING DURING INTRAOPERATIVE CHALLENGES- THE CALGARY STUDIES:
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).
- 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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