Taking a Chance or Playing It Safe: Reframing Risk Assessment Within the Surgeon's Comfort Zone (U of T)

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Introduction

The practice of surgery is associated with inherent risk and potential harm to patients, sometimes caused by poor decisions and errors.^[1] As a result, regulatory bodies are increasingly being held accountable for ensuring adequate self-regulation among surgeons and placing increasing emphasis on system-wide analyses of quality-assurance and quality-improvement strategies.^[2–5] Although system-based understanding of error has evoked positive change in surgery,^[6–9] factors affecting self-regulation by individual surgeons and their effects on surgeon behavior and decision making have received less attention as a focus of research.^{[10–12]....}

Methods

The subjects for this study were surgeons working at tertiary referral academic centers affiliated with the University of Toronto. After obtaining appropriate research ethics board approval, surgeons were contacted by e-mail and their voluntary participation in this study was requested....
 

Results

Eighteen semistructured interviews lasting approximately 60 minutes were conducted. Thirteen subjects were males. Our sample included 7 general surgeons (representing subspecialties including hepatobiliary surgery, transplantation, breast oncology, colorectal surgery, pediatric surgery, and bariatric surgery) 2 thoracic surgeons, 2 cardiac surgeons, 2 urologists, 2 orthopedic surgeons, 2 gynecologists, and 1 vascular surgeon. Three had been in practice less than 10 years, 13 had been in practice more than 10 years, and 2 were retired. Our sample included surgeons who demonstrated characteristics that might place them along various points of the risk taking spectrum as outlined in Table 2.....

Table 2.  Spectrum of Risk-taking Behavior

Type of Surgeon	Representative Quotation
Timid Surgeon	"It's that kind of obsessiveness on my side that's aging me at an incredible rate … affects my tolerance for taking chances … I think that the anxiety for me is, it's interesting, you ask about tolerance for cases and stuff. 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." (N9)
Pioneer Surgeon	"When I was learning how to do (type) surgery it was just a matter of going slowly and having really good help, and sometimes practicing. I mean, we practiced the (procedure) on the pig until we knew all the maneuvers … ." (N13)
Cowboy Surgeon	"Yeah, I do (type) surgery. I was never trained to do it … the first time I did a (procedure) I just had the photos from the Journal in the room, in terms of where to make the incision and what to do, like a recipe in a cookbook; and I did the case. I never saw one or was taught one." (N4)

  This has the potential to improve the culture of surgery and lead to a more thoughtful approach to clinical decision making.