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Surgical Decision-Making: More Questions than Answers?
RifatLati andAbbasSmiley
3
Introduction
How do we surgeons make decisions under what
can be inauspicious conditions is not entirely
clear. One would think and hope that we have
streamlined this process clearly by now since
such decisions are made countless times daily
across the world. Dissecting the anatomy of this
process is of great importance to all surgeons and
those who work with surgeons. Most importantly,
however, is the question, do patients understand
entirely the thought process of their surgeon and
how is this incorporated into the consent for the
operation? Many of us make decisions for which
later we may not have solid reason why we did it.
Usually, these are decisions made on the basis of
“a gut feeling” or “intuition” or the “gray hair
effect” among other “techniques.” The surgical
decision-making process is complex, demanding
the integration of evidence, inference, and the
The authors has no nancial or proprietary interest in the
subject matter or materials discussed in the manuscript.
R. Lati (*)
Department of Surgery, The University of Arizona,
Tucson, AZ, USA
Tucson Medical Center, Department of Surgery,
Tucson, AZ, USA
e-mail: Lati@surgery.arizona.edu
A. Smiley
Department of Surgery, University of Arizona,
Tucson, AZ, USA
experience, but often times it goes beyond the
evidence and it becomes a matter of creativity
and intuition [1]. How do we surgeons make
decisions under what can be inauspicious conditions is not entirely clear. As conductors of the
operation, or this most complex surgical symphony, we are cognizant of the intricacies of each
decision and complexity. Yet, despite the enormous implication of the surgical decision- making
process (SDMP) on surgical outcomes, the subject has not received adequate attention [1].
Furthermore, while evidence based is for the
most part the standard of care and the modus operandi for most of us surgeons, the question “how
do we surgeons make intraoperative decisions?”
has not been answered and is often not understood by even co-surgeons, residents, or other
assistants. Or perhaps, irrespective of the fact that
we make decisions, most of the times on evidence based, and/or intuition, often we surgeons
have difculty in describing exactly how we
came to specic decisions during surgery. The
question is why we do not talk more about it? Are
we simply too busy clinically, day in and day out,
and do not have time to study and dissect our own
decisions? Or, do we simply think that is the way
we do, our mentors did it before us, we do, and
we teach the youngsters the same procedure or
the same elements of the surgical procedure.
How to perform an evaluation of the surgical
decision while gaining a better understanding of
a seemingly gut-level process, which helps surgeons combat the external factors experienced
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
R. Lati (ed.), Surgical Decision-Making, https://doi.org/10.1007/978-3-031-67391-7_3
15
16
R. Lati and A. Smiley
before and during surgery, is wholly another subject altogether. Clearly, there are many factors
that affect decision-making for surgeons before
and during operations. These factors are experience and training, previous personal outcomes,
the physiologic state of the surgeon, the harmony
of teamwork, external factors at work, and the
surgeon’s ability to adapt quickly to a changing
environment, are the main ones. The aim of this
chapter is to set the stage for the entire book on
this complex and very important process, which
if done properly and timely may prevent,
minimize, or avoid altogether serious intraoperative and postoperative complications. The recent
developments in articial intelligence (AI) and
super computers will undoubtedly add more
interesting discussions to the role of AI in surgical decision-making. As of now, there is no doubt
that surgical decision-making is both a science
and an art, and involves intuition. Theories on
naturalistic and complex problem-solving methods have attempted to explain the decisionmaking processes of high-risk professionals.
However, these theories often lump surgeons
together with other professionals, such as pilots
and nuclear plant scientists, whose decisions
require exceptional accuracy, and creativity [1].
It is customary in the literature to compare pilots,
surgeons, and some other high-demanding professions, and gure out how do they all make
decisions when in a difcult situation.
Later in this book, in a separate chapter, I will
delve into a comparison between the surgeons
and the pilots, highlighting common elements in
their daily routines, such as the use of checklists
before commencing procedures, but in this introductory chapter, I will set the stage for further
discussion. While both professions involve continuous vigilant monitoring, crisis prevention,
and resolution when it occurs, pilots rely on standardized checklists during emergencies, whereas
surgeons heavily depend on their experience,
training, and intuition, and decide based on
patient’s physiology at hand. Unlike pilots, surgeons face the challenge of making critical decisions independently, even though they operate
within a team. Pilots, on the other hand have been
assisted and or directed by computers, and in
recent years, advanced super computers, which
control, just about everything that aircraft should
do or not do, and there is not much that pilots can
change on their own. The inability of pilots to
take over the computer software brought down
two Boeing Max 737 with catastrophic consequences [2]. Moreover, the unmanned aircrafts
(airplanes, drones, and other ying machines
with extraordinary precision) have become very
common, both in peace and more so in conicts,
and may render pilots unnecessary, although they
are still controlled by someone somewhere in this
planet of ours. Humans control a number of
sophisticated unmanned aircraft in other planets
as well. What will be the role of articial intelligence and computer programming in the airline
industry in the future, remains to be seen.
The Complexity ofSurgical
Decision-Making
Several factors contribute to the complexity of
surgical decision-making, distinguishing it from
other highly demanding professions and underscoring its unique challenges.
Challenges inStandardization
While the aviation industry has successfully
implemented a stepwise checklist model for
pilots, the surgical eld lacks a direct equivalent.
Unlike the standardized steps universally followed by pilots in aviation, surgeons encounter
difculties in standardizing their decisionmaking processes. Although the WHO Surgical
Safety Checklist was created to enhance teamwork, communication, reduce errors, and adverse
events in surgery, it does not directly address the
intricacies of intraoperative surgical decisionmaking and the dynamic environment of the
operating room.
While certain operations adhere strictly to
standardized steps, most surgical procedures
involve exible intra-operative steps. Even routine operations like cholecystectomy vary in
instrument usage and technique (open, laparo-
3 Surgical Decision-Making: More Questions than Answers?
17
scopic or robotic) among individual surgeons.
This individualized approach hinders the creation
of a reliable, reproducible, and easy-to-follow
step-wise surgical model, making standardization difcult, even in the face of evidence of preferred practice [3].
Although general safety standards exist, surgical steps lack subtle rules, allowing surgeons
considerable discretion. A four-grade classication of intraoperative difculties, reecting the
diverse challenges surgeons encounter has been
proposed [3], but it is not universally adopted. If
we concede that we will not be able to standardize every thought of the surgeon, or every move
in the operating room, is there a way that we can
clean up the process of surgical decision-making
from all external factors and make it dynamic, yet
consistent. If we could achieve this consistency,
trainees anywhere in the world can have access to
a consistent model every time they do the given
procedure. What will constitute “ consistency” is
another matter to be discussed and dened, altogether. Will all the surgeons around the world act
like robots and behave as creatures with no “brain
and emotional input”? Obviously, the practicality
of such an attempt will certainly be an impossible
mission. Yet, such models are being examined
and created, practiced and reported. The fact is
that we surgeons have simply not written enough
to explain how we have arrived at a particular
decision intraoperatively. The reasons for this are
multifactorial as well, but the current ways of
reporting data on our outcomes including very
sophisticated statistical analyses do not permit
such reporting, and thus there is a huge void of
literature describing surgical decision-making
processes. Just try to write a paper where you
describe your thoughts, and see if it will be published in any peer reviewed journal.
Individualization inSurgical
Procedures
The individualization of surgical approaches
stems from various factors, including training,
education, institutional practices, geography
(location), and institutional culture and memory.
At the Mayo, Cleveland, and other major clinics
around the world, changes are slow. The memory
and the culture prevail.
Even for routine surgeries, such as intestinal
anastomosis, variations exist in techniques,
whether stapler or hand-sewn [4, 5, 6, 7]. First,
there are a number of variations on stapler techniques, and certainly a number of variations on
the hand-sewn technique: single layer, double
layer, silk, vicryl, PDS, and other suturing materials are all used. Even when we narrow the discussion to one type of suture, for example silk
suture, one surgeon may use only 2.0 silk, while
another surgeon never uses 2.0, but instead uses
3.0 silk; the differences on outcomes are so minute, but each individual surgeon would have a
strong opinion on why he or she uses their preferred type of sutures. Because it not easy to
explain these individual preferences, it comes
back to the surgeons’ education and training,
technology available to the surgeon, institutional
tradition, region, and nally, the culture of the
surgeon and the patient that is being operated on.
These simple variations, underscore the challenge of creating standardized surgical models.
Intraoperative Decision-Making
The intraoperative decision-making process is
complex and can be difcult. It draws on the factors that we outlined above, but few factors such
as leadership ability, mental state, physiology,
and creativity, as well as objective data from the
patient’s physiology and anatomy. Flexibility and
an open-minded approach, along with a respect
for sound surgical principles, are most important.
The physiology of both the patient and the surgeon is imperative. Still, most difcult intraoperative decisions, as mention above, are made
“on the y” and are hard to theorize, quantify,
categorize or explain. Additional work, especially from and on surgeons themselves, is
needed to delineate further how we make lifechanging intraoperative decisions.
The construct of situational awareness can be
applied to these “gut feeling” evaluations. How
situational awareness and decision-making is
18
R. Lati and A. Smiley
affected by factors such as sleep deprivation,
alcohol, or other substance consumption and
other lifestyle habits is most important in understanding the decision-making process.
Leadership, Creativity, andSurgical
Decision-Making
Apart from the technical aspects, a surgeon’s
leadership ability, often overlooked, proves crucial in navigating complex and unexpected
intraoperative challenges. Managing adroitly crises by applying technical skills, clearly delegating tasks, and communicating effectively can
signicantly impact outcomes. Intraoperative
decision- making involves monitoring, assessing
situations, taking appropriate actions, and reevaluating patient responses [8, 9], While surgeon
may have a lot of data to consider, eventually he
or she has to rely on their own experience and
knowledge, their grasp of the patient’s clinical
information, and occasionally on their assistants’
help. A dynamic stepwise model of the surgeons’
intraoperative decision-making process involves
monitoring and reassessing the situation, taking
appropriate actions, and reevaluating the patients’
response. This dynamic model encompasses
intuition, recognized as “recognition-primed
decision-making,” analytical ability, and creativity [10]. The surgeons’ mental states play a vital
role, as evidenced by studies monitoring cardiac
arrhythmia and emotional levels during different
stages of surgery [11]. In this study, surgeons
were monitored using EEC, while opening the
wound during the operation process, and while
closing the skin immediately after the operation.
From the ECG recordings, indices reecting cardiac arrhythmia and emotional levels were calculated. The authors concluded that the process of
decision-making during the vital stages of operations causes a fall in the coefcient of heart rate
variability, the variance of R-R intervals, and the
variability range of R-R intervals. During all the
stages of surgery studied, and immediately after
the operation, an increase in tonus of the sympathetic nervous system occurs in surgeons, indi-
cating a rise in emotional level [11]. Factors such
as task visualization, communication, and mental
models have also been identied as critical in surgical decision-making [12, 13]. Creativity in
complex surgical procedures is a key element in
shaping surgical practices and challenging established norms [14]. While adhering to sound surgical principles, surgeons must remain
open-minded and exible to adapt to new intraoperative challenges. Nowhere is that model
more applicable than in complex reoperative surgical procedures, which are often associated with
an array of unanticipated problems [14]. In the
author’s opinion, an important non-technical
component that has not received sufcient attention is the surgeon’s leadership ability.
Inuence ofTechnology
onDecision-Making
The evolution of technology has signicantly
inuenced the peri- and intraoperative decisionmaking process by using technological tools and
modifying decisions accordingly [15]. One has to
review the progress made only within the last few
decades, from all open surgery, to laparoscopically, to endovascularly and robotically assisted,
just basically every surgical procedure, to see the
real effect of technological advances. The availability of technology shapes surgical practices,
particularly articial intelligence, as evidenced
by the historical development of surgical
advancements. However, the increasing reliance
on technology prompts contemplation of a future
where surgical decisions might be guided by
advanced systems, possibly surpassing human
capabilities.
Summary: From all the elements associated
with the entire continuum of complex surgical
process, for us as surgeons, surgery itself is and
should be the easiest one. Deciding what to do,
and more often what not to do, is more complex,
more demanding, more tasking, and requires
more thinking and planning from the surgeon and
the surgical team than the procedure itself.
Because there are no minor or simple surgical
3 Surgical Decision-Making: More Questions than Answers?
19
interventions, surgical decision-making is complex in every procedure, in every patient, and all
the time. Each complex surgical procedure carries signicant risks and complications, whether
performed alone or in combination, if every detail
is not executed exactly. Surgery is a symphony
where everyone plays their notes based on the
script and are led from the conductor. Yet, there is
a difference between the emergency surgery that
is required to save someone’s life or relieve the
pain and suffering and elective surgery. Even
more different is the surgical decision in prophylactic surgery [16].
Consequences ofSurgical
Decision-Making
Sometimes not all that we do goes as smoothly as
planned, and not every operation is successful. In
the past, surgeons have been known to use the
saying: “The surgery was successful, but the
patient died.” While this is not uttered as often
today, sometimes everything during the operation
did go as we had wished, but the patient does not
recuperate, develops one or more major complications, or worse the patient dies. Even when
things do go well, the patient may still need to
undergo a subsequent procedure, another exposure to anesthesia, endure a longer hospital stay,
and experience a number of unforeseen issues.
The cost of surgical errors is massive, and probably cannot be quantied realistically, as many of
the errors go unnoticed, and often outcomes are
“assigned” to the patient’s disease or at best to
“opportunity for improvement.”
It’s important to note that the exact costs can
vary widely depending on the severity of the mistake, the resulting harm to the patient, and the
specic circumstances surrounding the incident.
Healthcare systems continually strive to improve
safety measures to minimize the occurrence of
surgical mistakes and mitigate their associated
costs. One only need to consider the impact of
potential complications to appreciate that no surgery should be dismissed as minor or merely routine. Does surgical decision-making contribute to
postoperative complications?
The Factors Aecting Intraoperative
Decisions
As a medical student, a surgical resident, and as a
young faculty, I was fascinated by the surgical
decision-making and how surgeons came up with
them. Often time, for the same disease process
and the same diagnosis, my professors would
have different approaches and often different or
alternative decisions altogether. The rst edition
of this book was the result of this interest.
Recently, I have expanded the surgical decisionmaking to the geriatric population, as the fastest
growing group of world population decisions in a
number of situations [17].
Distracting Factors onPerioperative
Surgical Decision-Making
andDisruption ofSurgical
Symphony
The most important factors in surgical decisionmaking that have not attracted enough attention
are those that we surgeons encounter in the preoperative phase. These factors, and I call them
distracting, may have a profound effect on outcomes. Such perioperative factors could be the
state of the patient’s physiology and age (often
we act differently in young patients compared to
elderly ones), comorbidities or lack of other diseases, staff or family members of the staff (do we
act differently when a patient is a doctor or nurse
or a family member of the healthcare provider
who we know or not), patient is famous or a wellknown persona (we all have received those phone
calls from people that know someone popular
and wishes to have the best surgeon to take out
the gallbladder or x the hernia), your own experience with the patient and the family in the past
and other factors. How many times, we have
dealt with such factors in our practice and when
things did not go as well as we wanted. In Kaizen
conferences, we the surgeons bring these factors
up in our conversation: “The family wanted
everything on 92 years old grandpa” who in
everyone’s opinion, upon hearing the story, felt
he had no chance of making it; or more common,
20
R. Lati and A. Smiley
“this is not a mortality from the operation”; “
family withdrew care” after the procedure, which
we should not have done to begin with. A wife of
one my high-ranking bosses in one of the institutions that I worked for in the past, and who had
severe mechanical small bowel obstruction from
previous surgeries, insisted that I manage her
non-operatively. I made it clear that she needs an
operation. I was glad she allowed me to operate
on her. Clearly, I resisted to distraction, and did
not succumb to this external factor. A delay in the
operation and she would have had gangrene of a
large segment of the small bowel.
What the crew of this ship, named “The
Operating Theater,” does and does not do will
have profound consequences. A team of surgeons, nurses, an anesthesiologist, scrub technicians, a radiologist, and scheduling personnel,
are all led by the surgeon to execute a surgical
procedure affecting the patient’s life, and the
lives of their family, friends, and their community. Everyone expects that this orchestrated set
of tasks will be executed like a perfectly coordinated symphony. After all, this is a hospital with
highly-trained professionals. Other distracting
factors are the operating team composition, such
as the anesthesiologist, your scrub nurse or tech,
the equipment that is missing or does not work.
Each and every one of these factors affects the
outcomes of surgery, and most people have not
studied them. We need to.
Each individual surgeon will differ on what
they identify as a potential stressor, but those
commonly reported include laparoscopic (versus
robotic) surgery, procedural complexity, distractions, and lack of time [18]. Observational studies indicated that movement and case-irrelevant
conversations were the most frequently occurring
distractions, but equipment and procedural distractions were the most severe [19]. While distractions in particular may lead to an increase in
surgical errors, because tasks that require more
concentration tend to be more stressful, it has
been shown that deliberate practice and minimization of intermittent auditory distractions can
help a surgeon to better multitask during a procedure [19, 20]. Surgical trainees undergo extensive
medical training that prepares them to form a
cognitive representation for comparison that
stimulates arousal, alertness, and focused attention. Brain structures involved when confronting
a stressor are the hippocampus (involved in retention and memory), the amygdala (emotional
stimuli processing), and the prefrontal cortex
(part of the executive function control).
Psychological stressors, such as performing complex surgery, will activate regions such as the
amygdala which promotes the memory of salient
but not neutral information. For example, when
faced with a surgical procedure, a surgeon may
recall key complex procedures more accurately
than procedures that are not as pressing or salient.
Can one extract a memory that has been stored
somewhere in the brain, under stress?
This is a uid and dynamic process [9, 21],
encompassing components such as intuition (also
known as “recognition-primed decision-making”
analytical ability), exibility, and creativity [22].
This model is particularly important in complex
reoperative surgical procedures, which are often
associated with an array of unanticipated or
unrecognized problems preoperatively. While
performing, a take-down ileostomy and endcolostomy (serving as mucus stula, as described
in medical record) a few years ago, I found a
couple of surprises that complicated the operation greatly. First, instead of ileostomy, patient
actually had a jejunostomy (mid small bowel
stoma) and this explained why he could not gain
weight since he was operated three years ago in
another hospital. Second, there was an unrecognized small bowel to end-colostomy stula,
requiring resection (20 cm from ligament of
Trietz). And third, he required a colo-colonic
anastomosis. In all, I spent about six hours dissecting and freeing his intestines from severe
adhesions, and performed three anastomoses,
plus complex abdominal wall reconstruction, as
he had a known large abdominal defect requiring
posterior component separation. To make the
proper decision, it is essential to be continuously
aware of the patient’s physiologic status—including uid status, urine output, use of blood and
blood products, bleeding, use of medications
used by anesthesiologist (such as vasopressors),
and biochemical endpoints of resuscitation,
3 Surgical Decision-Making: More Questions than Answers?
21
because, even when the operation is going well,
the biochemical prole of the patient may not be
optimal, or even acceptable, and this may directly
affect the outcome of the surgery. This patient, a
41-year-old man, did very well and was discharged home having had his gastro-intestinal
tract fully restored and functional.
In addition to the surgeon’s training, education, leadership ability, physiologic and mental
state, creativity (or simply making things up at
times) might be the most critical element of all.
Creativity in the service of excellence does not
come easily, however. It takes dedication. It takes
a lifetime of continuously studying the art and
science of surgery.
The Surgeons’ Physiology andState
ofMind
As outlined earlier in this chapter, the surgical
decision-making process (SDMP) depends on
several factors, but most importantly, nothing
will affect the outcome of a surgical procedure
more than the decisions of the surgeon, and the
state of mind and the physiology of the surgeon,
followed by the patient’s condition and physiologic state and the gravity of the disease. Patients
or their families very often ask us: “Doctor,
please get a good night’s rest.” or “Doc, have you
had a good night’s sleep?” We will discuss this
topic in more detail in Chap. 3, but let us stress
that the optimal physiology and the optimal state
of mind of the surgeon often set the stage for the
entire surgical symphony to function optimally or
to become a chaotic state.
The lifestyle of us surgeons is intricately tied
to the demanding nature of our profession. This
role comes with a set of challenges that signicantly inuence the lifestyle choices and experiences of surgeons. Among the lifestyle elements,
sleep is the most important one, affecting wellbeing and performance of surgeons. A study published in the Journal of the American College of
Surgeons found that sleep deprivation negatively
impacts surgical skill performance and decisionmaking. Adequate sleep is essential for maintaining cognitive function, concentration, and
decision-making skills, all of which are critical in
the high-stakes environment of surgery [23].
Here are some key points regarding the role of
sleep in a surgeon’s lifestyle:
1. Cognitive Performance: Sleep plays a vital
role in cognitive functions such as memory
consolidation, problem-solving, and attention. Surgeons need to be sharp and focused
during procedures, and lack of sleep can
impair these cognitive abilities. Another study
in the Archives of Surgery emphasized the
importance of ensuring surgeons get adequate
sleep to maintain optimal cognitive and motor
skills during surgeries [24]. Sleep loss can
lead to impaired cognitive function, affecting
memory, attention, and decision-making,
which are critical aspects of surgical performance [25].
2. Precision and Coordination: Surgical proce-
dures require precise movements and coordination. Fatigue and sleep deprivation can
affect ne motor skills, leading to a potential
increase in errors and complications during
surgery.
3. Reaction Time: Quick and accurate decisionmaking is crucial in the operating room. Sleep
deprivation can slow down reaction times and
impair judgment, putting both the surgeon
and the patient at risk.
4. Emotional Well-being: Lack of sleep can
contribute to mood disturbances, irritability,
and increased stress levels. Surgeons often
work in high-pressure situations, and adequate sleep is essential for maintaining emotional resilience and overall mental health.
5. Patient Safety: Sleep-deprived surgeons are
more prone to errors, which can compromise
patient safety. Adherence to proper sleep
hygiene is not only important for the wellbeing of the surgeon but also for ensuring the
best outcomes for patients.
6. Long Working Hours: Surgeons often have
demanding and unpredictable schedules,
involving long working hours, night shifts,
and on-call responsibilities. Balancing work
and personal life while ensuring sufcient
sleep can be challenging.
22
R. Lati and A. Smiley
7. Adaptability: Surgeons need to be adaptable
to varying work schedules and unexpected
emergencies. Establishing healthy sleep patterns and nding effective strategies to manage fatigue becomes crucial for maintaining
performance under different circumstances.
The role of sleep in a surgeon’s lifestyle is pivotal for maintaining optimal cognitive function,
precision, and overall well-being. Surgeons must
prioritize adequate sleep to ensure they can perform at their best and provide safe and effective
care to their patients.
There is a multifaceted relationship between a
surgeon’s professional responsibilities and their
personal lifestyle, considering factors such as
work hours, stress, and the pursuit of work-life
balance.
Most surgeons often face demanding work
schedules that extend beyond the conventional
9-to-5 timeframe. The nature of surgical emergencies and the unpredictability of cases mean
that surgeons frequently work long hours, including evenings, nights, and weekends. This irregular work schedule can lead to challenges in
maintaining a healthy work-life balance. The
constant demand for availability and the pressure
to respond promptly to emergencies contribute to
a lifestyle that is often characterized by high levels of stress.
The stress associated with surgical practice is
not only a result of long working hours but also
stems from the inherent responsibility that comes
with making critical decisions during surgeries.
The life-and-death nature of surgical procedures,
coupled with the intense focus required, can lead
to signicant mental and emotional strain.
Surgeons must cope with the stress of making
split-second decisions, managing unexpected
complications, and dealing with the emotional
toll of patient outcomes.
Research indicates that the lifestyle of surgeons can be physically demanding as well.
Prolonged hours in the operating room, coupled
with the need for precision and concentration,
can contribute to musculoskeletal issues and
physical fatigue. Maintaining peak physical and
mental condition is crucial for surgeons, as any
lapse in focus or physical capability can have
severe consequences.
Despite the challenges, many surgeons nd
fulllment in their work, deriving a sense of purpose from the positive impact they have on
patients’ lives. The satisfaction of successfully
performing a complex surgery and contributing
to a patient’s recovery can offset some of the
stresses associated with the profession. This
intrinsic motivation often plays a signicant role
in shaping the lifestyle choices of surgeons.
Efforts to address the impact of a surgeon’s
lifestyle on their well-being have led to increased
awareness of burnout within the profession.
Burnout, characterized by emotional exhaustion,
depersonalization, and a reduced sense of personal accomplishment, is a prevalent issue among
surgeons. It is essential to acknowledge the
importance of mental health and well-being in
the medical profession and implement strategies
to mitigate burnout.
In recent years, there has been a growing recognition of the need for work-life balance in surgical practice. Hospitals and healthcare
institutions are implementing measures to support surgeons in maintaining a healthier lifestyle.
These measures include implementing exible
scheduling, providing mental health resources,
and encouraging a culture that prioritizes
self-care.
In conclusion, the lifestyle of surgeons is a
complex interplay between the demands of their
profession and their personal well-being. The
long hours, high stress levels, and physical
demands of surgical practice shape the lifestyle
choices of surgeons. While the profession brings
unique challenges, it also offers a sense of purpose and fulllment. Efforts to address burnout
and promote work-life balance are essential to
ensuring the long-term well-being of surgeons.
As the healthcare landscape evolves, it is crucial
to continue exploring ways to support surgeons
in navigating the delicate balance between professional and personal life [26, 27, 28].
3 Surgical Decision-Making: More Questions than Answers?
23
Overlooked Behaviors Impacting Surgical Decision-making Outcomes
When we discuss the outcomes of surgical
patients in our quality improvement (Kaizen conference, formerly known as Morbidity and
Mortality), we classify some of the complications
as “potentially preventable” or what we say nowadays “room for improvement”, however, whatever we call them, technically these are errors. I
have identied several errors or omissions that I
have called “Under radar behaviors,” which are a
de-facto part of surgical decision-making, and
which do not get reported at all, or are barely
mentioned during quality review of clinical
outcomes.
1. Time from patient arriving in the emergency
department to being seen by the surgeon.
2. Time from decision to operate to actually
making an incision.
3. Time from when the patient is in the operating
room till we actually make an incision (surgeon does not follow the patient to OR).
4. The use of useless CT scans, and/or other tests
called “on the way to operating room.”
5. “Dropping” of the patient in the ICU to the
ICU team without proper communication,
proper involvement, and complete ownership
of patient, while working together with the
team at the bedside.
6. Use proper vocabulary when we review quality issues and avoid entirely such worlds like:
“perhaps,” “probably,” “maybe” when we
should teach our trainees and tell our colleagues what happen exactly. Be ready always
to have evidence ready, and say how would
you have done it.
7. Audit the test ordered and decision made
based on useless tests ordered daily. These
test that most of the time go unnoticed adds
greatly to the hospital cost.
8. Audit communication with anesthesia
(patients is placed on vasopressors, and the
surgeons does not know that).
The majority of these are under the radar of
omissions or frank errors, but silenced or simply
ignored, and do not get mentioned anywhere.
Occasionally, there are some serious errors that
become the subject of intense study both by surgeons and non-surgeons alike. These “errors”
have been classied by a number of organizations. Yet, not everything that goes wrong occurs
due to an error; such instances have been called
“adverse events”, “a near miss”, and “a mistake”.
Other classications of the errors include technical (i.e., one should have done a different move,
or used a different approach), error in judgment
(i.e., one did not realize how sick the patient was,
or totally missed the diagnosis), or pure negligence (we need not dwell on this one, but sufce
it to say it occurs far less than attorneys would
have the world believe).
Recently, I observed a senior surgeon getting
lost somewhat in the abdominal wall. He was
“too concentrated on one point” and was clearly
missing a bigger picture of the reconstruction.
Getting “lost” is not that difcult, however. This
is why surgical decision is constantly changing
and is very dynamic. Yesterday, I observed a surgeon maturing, clearly an ischemic colostomy,
but he was thinking that it will be alright. It will
not. It did not. The other day, frank necrotic ileostomy was being watched for an entire week. “He
was placed on vasopressor, and mucosa died”
was explained to me. Not so. The stoma had technical issues impeding blood supply. There are a
number of factors that may cause disruption of
the surgical procedures that comprise the “symphony” of standard perioperative care. The
researchers from Mayo Clinic prospectively analyzed ow disruptions by a trained observer in
thirty-one cardiac surgeries, and described teamwork/communication failures, equipment and
technology problems, extraneous interruptions,
training-related distractions, and issues in
resource accessibility. Surgical errors increased
signicantly with increases in ow disruptions;
teamwork/communication failures were the
strongest predictor of surgical errors [29]. In
order to ensure a perfectly conducted surgical
24
R. Lati and A. Smiley
symphony, the goal of every surgeon should be
pursuing a high-quality safety program. The type
of errors that disrupt surgical symphony has been
reported [30]. In this study, 78.3% of complications that occurred in 332 patients (3.4%) were
attributed to errors in surgical technique (63.5%),
errors in judgment (29.6%), inattention to detail
(29.3%), and incomplete understanding (22.7%).
In 34.4% of cases, patients had a prolongation of
hospitalization, 25.1% had temporary disability,
8.4% permanent disability, and 16.0% died. In
20%, the error was a “mistake” (the wrong thing),
and in 58% a “slip” (the right thing done incorrectly). System errors (2%) and communication
errors (2%) were infrequently identied [30].
The authors of this excellent study concluded that
after surgical technique, most surgical errors
were caused by human factors: judgment,
inattention to detail, and incomplete understanding, and not to organizational/system errors or
breaks in communication.
The Never Event
In order to continue to improve the quality of our
services the medical/surgical community have
coined a new terminology: the never event, and
we have gone to great lengths (rightly so, perhaps) to establish “never event” notion. Surgical
never events are dened as errors such as wrongprocedure, wrong-site, retained foreign body, and
wrong-patient events. Such errors are evaluated
continually, and have received great public interest. While the consensus among surgeons, administrators, patients and their attorneys is that these
events are completely avoidable, they occur quite
often. According to the data from the National
Practitioner Bank (NPDB) of the United States
reviewed by Mehtsun etal. [31], between 1990
and 2010, over $1.3 billion was spent on malpractice lawsuits associated with surgical never
events. A total of 9,744 malpractice cases related
to never events occurred, with an estimated of
4,082 surgical never events occurring each year
in the United States alone. The most common
type of event was retained foreign body
(n=4,857; 49.8%), followed by wrong- procedure
(n = 2,447; 25.1%); wrong-site (n = 2,413;
24.8%); and wrong-patient surgery (n = 27,
0.3%). Approximately 7% of these cases ended
in death, 32% had permanent injuries, and 59%
had temporary injuries. Perhaps most disturbing
about this report is the fact that of physicians
named in a surgical never event claim, 62% were
named previously in a malpractice claim, and
12.4% were later named in at least one future surgical never event claim [31]. This is a truly a disturbing trend. Even worse, we do not know the
extent of this major problem worldwide, particularly in the developing world. Factors related to
the individual physician seem to be the most
important items to consider in never events. The
physician’s age (40–49), <20 years from graduation, additional malpractice reports, state licensure disciplinary reports and clinical privileges
reports were all statistically signicant
(p=0.001) for physicians involved with surgical
never events in this study.
The Institute of Medicine provided even more
startling statistics that exemplify the gravity of
the situation. On an annual basis in the United
States, more people die from medical errors than
from motor vehicle accidents, breast cancer, or
AIDS [4]. According to a report published by
IOM, between 44,000 and 98,000 people may die
in hospitals each year due to errors. The report
was written to evaluate, quantify, and provide
suggestions for what can be done to increase
safety and quality in the health care system. The
IOM suggested the development of checklists
and protocols to combat common errors [32].
While the WHO [33] has provided a checklist to
the surgical team for save surgery, but this does
not reduce the overwhelming complexity of modern surgery, the mechanistic and cognitive processes that surgeons grapple with that are less
understood. These data have been questioned and
errors are the cause of death.
Even more signicantly, factors, such as stress
and physiological responses to stress that affect
these processes and contribute to error rates, need