Behind The Curtain S u r g i c a l J u d g m e n t B e y o n d C o g n i t i o n

Carol-Anne Moulton, MBBS, MEd, PhD, FRACS

I am notcut out to do this

Surgical Judgment

Moulton et al. (2007)

Slowing DownWhen You Should

Attention Threshold

Novice

Primary activity

Spare capacity

Expert

Primary activity

Spare capacity

Kahneman (1973)

Attention Threshold

Effortful

Primary activity

Spare capacity

Automatic

Primary activity

Spare capacity

Slowing Down

T h e Moment

Slowing Down

“…my efforts during these moments of crises were

consumed with the anxiety I was feeling and

intermixed with feelings of inadequacy, uncertainty,

reputation and ego.”Senior Surgeon, Interview

The Unspoken

Qualitative

Charmaz (2000)

Reflecting on Individual Factors in Surgical Adverse Events

Leung et al. (2012)

Un-AvowedAvowed Dis-Avowed

Ginsburg et al. (2003)

Avowed

Avowed

“I gave the patient a stoma. He didn’t

want one but I really felt it was the best

thing to do, the safest thing to do for

him.”

(IV-401)

Un-Avowed

Un-Avowed

“I think the pressure of the clock is distracting

and you hurry things along...we know that it is

a wrong thing to operate by the clock but

we’re put in a position where we’re in some

ways forced to do that.”

(I-01)

Dis-Avowed

Dis-Avowed

“There are ones like, well, do I really

need this help, do I want to seem like a

loser, am I going to call someone?”

(I-25)

T h e Moment

“I remember all of my deaths . . .”

THE FALLSurgeons’ Reactions to Failure

Luu et al. In press.

Unique

UniqueY o u a r e n o t

“Absolutely there is.

No question in my mind.”

(I-011)

“Who sent you to me? Did you hear

that I am an outlier?”

(I-008)

“I can only speak on the outside,

but they appear to have stuff slide

off of them.”

(I-002)

“You didn’t think this bothered me

as much as it did right?

(I-009)

The

Kick

Tachycardia

“There’s tachycardia…and there’s

unease…anxiety.”

(I-019)

Imposter

“I’m not entitled to walk around

with my lab coat and my scrubs

and be a surgeon or a scientist or

whatever. You just feel personally

devalued.”

(I-005)

Failure

“You kind of want to hide, run away

and hide in the corner and be

alone.”

(I-003)

Emotional

“I almost crashed into four parked

cars before I got out of the parking

garage that day. I was so

distraught … like I am not a guy

that cries, but…”

(I-001)

Incapacitated

“So you’re dealing with the

emotional turmoil and that morbid

feeling of you’ve done something

bad and it generally incapacitates

you.”

(I-005)

The

Fall

Was it my fault?

“Did I goof something or did I miss

something? Is it a technical

problem? So I relive the operation

and I go through the critical parts

of the operation.”

(I-003)

The

Recovery

Short Term

“I’m going to learn from this. I’m not

going to dismiss it and say, “Well, it’s

the patient’s fault” or “It’s the nurse’s

fault”, sort of learn from it whatever

the problem was and move on.”

(I-003)

Short Term

“And you can get up or not. If you

don’t get up, that’s slow suicide or

termination of what you do for a

living.”

(I-008)

The

Impact

Long Term

“I think that each mistake I make, or

each complication I have, or each

patient I bury, I think has taken a

little wee piece out of me.”

(I-008)

Long Term

“It's that kind of obsessiveness on my side that's

aging me at an incredible rate…affects my

tolerance for taking chances… I get to a point

where there are fewer and fewer cases that I

get really excited about…like I see the very

negative side of it or the negative is starting to

outweigh the positive”

(N-009)

Reputation

“The truth is you’re also worried about

yourself. I think, really, you’re worried

about your reputation, how people are

going to think of you, the finger

pointing…everyone in the community is

going to know.”

(N-002)

Expectation

Surgical RealityExperience

Social Cognition

Constructed Identities

Pratt et al. (2006), Gergen & Davis (1985)

Constructed Identities

“So someone who’s knowledgeable,

confident, decisive, and walks with

their head held high. They have that

like strut, that like surgeon’s walk.”

(J-001)

Constructed Identities

“You’re not supposed to be afraid,

you’re supposed to be in control,

you’re supposed to know everything,

you’re supposed to be able to do it.”

(J-003)

Looking Glass Self

Cooley (1902)

Looking Glass Self

“And then I believe that now he believes that

I’m not a qualified surgeon to be doing this type

of operation if I still make those mistakes. But

then what happens in my mind is I believe that

we have to now sort of start from the beginning

in which we’ll do again more and more

operations and then he’ll eventually think that

I’m an okay surgeon, and then he’ll let me do it

by myself thereafter.”

P-008

Looking Glass Self

“You have to have the confidence that you

can do it. Everyone has to be on your side and

it’s got to be a can-do kind of thing, because if

it’s not, then people start to eat away at you.

They second guess you. Are you sure? Do you

want me to call? And then you get self doubt

and lose your confidence and then you can’t

do your job.”(J-003)

Performativity

Goffman (1959)

Performativity

“It was a horrible case. And I couldn't identify the

rectum. I couldn't even identify the sigmoid...So I'm

operating with the senior resident and thinking to

myself, I'm a colorectal staff…and I can't even identify

the rectum...I'm not saying it to anyone else in the

Operating Room. I'm like, God. I'm like giving the

perception that I can tell what's going on here...I think I

must have spent a lot of time doing nothing...During

that time in the OR there's probably very minimal going

on in terms of actual operative patient care. It was like

taking care of myself…”

(K-

23)

Socialization

Hafferty (1991), Cassell (1991)

Socialization

“...when I presented my case they laughed...as soon as one

laughs then the other laughs...and no one has the balls to not

laugh. It's almost like a little club...I'm thinking, does anybody

have the nerve to not conform?...No one wants to be the

dumbest… no one wants to be the least informed, or the most

inquisitive. It's almost like when you have the big shots all

together you can't really be inquisitive, and if you're inquisitive

people laugh at you.”

(K-3)

Primary activity

Pressures to

Measure Up

Cognitive Capacity

Jin, et al. Ann Surg, 2013

“…And then the staff showed up just outside the

operating room to see how things were going, and I

can see the fellow getting completely nervous and

then completely changing and telling me “go faster”,

“come on, you have to grab it”, when beforehand we

were just going at a normal sort of slow pace... he got

nervous, to the point that we ended putting the kidney

upside down. So we had to take all the stitches out,

and put it back in again. ”

(P008)

Cognitive Capacity

Towards a More Mindful

SurgeonEpstein et al. (2008)

Towards a Surgical Decision

Vocabulary

Towards Surgeon

Wellness

Tools for building a different

Surgical Culture

Ministry of Research and Innovation Early Researcher Award

Royal College of Physicians

and Surgeons of CanadaMedical Education Research Grant

Physicians Services IncorporatedHealth Professional Research Grant

Behind The Curtain S u r g i c a l J u d g m e n t B e y o n d C o g n i t i o n

Glenn RegehrHelen MacRaeLorelei LingardSteven GallingerAnnie LeungShelly LuuJenny JinNathan ZilbertPriyanka PatelLaurent St. Martin

Simon KittoTina MartimianakisJacob GallingerLucas MurnaghanSandra deMontbrunTulin CilVicki LeBlancLisa Mark Carween MuiShira Gold