Surgical Education
To operate or not to operate? A multi-method analysis of
decision-making in emergency surgery
Peter Szatmary, M.B.B.Chir., M.Ed., M.A.,
a,
* Sonal Arora, B.Sc., M.B.B.S., M.R.C.S.,
a
Nick Sevdalis, B.Sc., M.Sc., Ph.D.
a,b
a
Department of Biosurgery and Surgical Technology and
b
Imperial Centre for Patient Safety and Service Quality,
Imperial College of Medicine, London, UK
Abstract
BACKGROUND: The ability to decide when to operate and when not to operate is a key surgical skill.
The aim of this study was to investigate factors affecting that decision.
METHODS: In phase 1, semistructured interviews were used to investigate how expert surgeons decide
when to operate. In phase 2, clinical case vignettes were constructed, and 22 general surgeons at various
stages of their training indicated whether they would operate and their confidence in patient outcomes.
RESULTS: Interviews answers centered on the theme of “patient outcome,” which was defined
similarly by all surgeons. In phase 2, surgeons chose to operate when they perceived the outcome with
an operation to be better than the outcome without. Surgeons with 5 years of experience were less
certain about what outcomes might be. These surgeons opted to perform significantly more operations
(40 4%) than surgeons with 5 years of experience (18 2%).
CONCLUSIONS: A subjective, balanced assessment of the likelihood of patient outcome is crucial
in deciding whether to operate. Novices face higher degrees of uncertainty, explaining differences in
decisions taken.
© 2010 Elsevier Inc. All rights reserved.
KEYWORDS:
Decision making;
Emergency surgery;
Qualitative outcome
assessment;
Surgical education
Research into surgical decision making is often carried
out with the aim of producing consensus or guidelines for
the management of common surgical conditions such as
appendicitis
1
or cholecystitis.
2,3
More recently, qualitative
“decision mapping” has been used to investigate and iden-
tify the decisions involved in caring for a surgical patient
from point of admission to point of discharge,
4
and quan-
titative approaches from behavioral science have been suc-
cessfully applied to modeling surgical judgment.
5,6
To date, little research has been carried out into the
thought processes of surgeons’ decisions of whether or not
to operate in given situations. Despite this, the decision of
whether to operate is seen by many as fundamental to the
practice of surgery and the ability to make that decision
appropriately as a key tenet of surgical skill.
7
Indeed, in the
well-renowned phrase from Kirk’s textbook of general sur-
gical operations,
8
the best surgeon is one who “knows when
not to operate.” Understanding the factors that influence this
decision-making process is critical if this hallmark of ex-
pertise is to be distilled into a teachable format.
The aim of this study was to investigate the process
involved in deciding whether a patient should be operated
on or not in an emergency setting. Specifically, the first aim
Dr Sevdalis is a member of the Imperial Centre for Patient Safety and
Service Quality at Imperial College Healthcare NHS Trust, which is funded
by the National Institute of Health Research. Dr Sevdalis is also funded by
the Economic and Social Research Council Centre for Economic Learning
and Social Evolution.
* Corresponding author: Tel.: 44-789-6223424; fax: 44-151-7065828.
E-mail address: dr.szatmary@doctors.net.uk
Manuscript received June 1, 2009; revised manuscript October 20,
2009
0002-9610/$ - see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2009.10.020
The American Journal of Surgery (2010) 200, 298 –304