Nav: Home

Under pressure: The surgeon's conundrum in decision making

July 09, 2018

In a small study based on conversations with 20 hospital-based surgeons, Johns Hopkins researchers say they found that most report feeling pressure to operate under severe emergency situations, even when they believe the patients would not benefit.

Results of the study, published in the May issue of the Journal of the American College of Surgeons, highlight the multiple factors and complexity that underlie decision-making, quality care and patient outcomes in life-and-death emergency situations, the researchers say.

"Conversations and decisions about surgical interventions and their risks are never easy, but they're even more difficult in emergency situations, and our study was designed to better understand -- in a qualitative way -- surgeons' thought processes during these times," says Fabian Johnston, M.D., M.H.S., assistant professor of surgery at the Johns Hopkins University School of Medicine. Few tools, he says, are available or demonstrated to be effective in objectively measuring these kinds of decisions.

To gain a better understanding of how surgeons approach decision-making with patients during life-or-death situations, Johnston and co-authors conducted face-to-face interviews with 20 surgeons whose specialties included trauma, vascular medicine and surgical oncology. All practiced at two large academic medical centers: The Johns Hopkins Hospital and the Medical College of Wisconsin. The vast majority of the surgeons (18 of 20) were male and white (16 of 20). The midrange age was 45 and the midrange number of years in practice was nine.

In audio recorded interviews either over the phone or in person, the researchers asked the surgeons what they thought were the most important considerations when deciding whether to operate on a patient who has what is likely a nonsurvivable injury or other emergent, acute medical problem such as a ruptured abdominal aorta. Interviews consisted of presenting the surgeons with two hypothetical case vignettes and 13 questions about what they would decide to do and what factors would go into the decisions.

Two surgeon investigators conducted the interviews and two other researchers analyzed them using a method of listening to the interviews for repeated ideas and elements, which were then organized into codes.

Their analyses of the conversations, the investigators say, found that five themes emerged: 1) the importance of surgeons' judgment, 2) the need for surgeon introspection, 3) the various pressures to operate: from the surgeons themselves, from the patients and/or their families, from colleagues or institutions, and from society and our culture, 4) the costs of operating -- medically, financially and emotionally -- and 5) the concept of futility and uncertainty around a decision to operate or not.

Overall, Johnston and the team found that most surgeons erred on the side of operating despite -- or because of the uncertainty of -- perceived futility of treatment.

One participant said, "I think that we do have this, as surgeons, 'the cut is to cure' situation ... pride in the patient, pride in the outcome, pride in what we do, and wanting the patients to do as well as they possibly can."

Another said, "As much as we internally believe when situations are futile and procedures shouldn't be done, that just goes against the grain of the pattern of practice in many parts of the hospital. So I think in those scenarios, I can't really say no" to operating.

Johnston says objective tools to assess risk are needed for more confident and patient-centered decision-making, and that studies such as the current one may help inform the development of such methods by identifying factors of most concern to surgeons.

"The goal, ultimately, is to empower surgeons to confidently advise against surgical intervention when the risks outweigh the benefits, and that goal requires data and support from peers and institutions," says Johnston.
-end-
Other authors on this paper include Jessica Ruck, Alison Conca-Cheng and Thomas Smith of Johns Hopkins, and Rachel Morris and Thomas Carver of the Medical College of Wisconsin.

To view the accompanying video please click here.

Johns Hopkins Medicine

Related Surgeons Articles:

Spine surgeons face COVID-19 challenges worldwide
Spine surgeons across the world are experiencing effects of COVID-19, including canceled procedures, changes in clinical roles, anxiety and risk of exposure to the disease themselves due to insufficient protective equipment.
COVID-19 evidence and strategies for orthopaedic surgeons
How should orthopaedic surgeons respond to the COVID-19 pandemic? A review in The Journal of Bone & Joint Surgery analyzes evidence and strategies for managing the novel SARS-CoV-2 virus - including critical lessons from past pandemics.
Surgeons successfully treat brain aneurysms using a robot
A robot was used to treat brain aneurysms for the first time.
Operating room reproductive hazards for female surgeons
Researchers in this review article discuss occupational reproductive hazards for female surgeons in the operating room, including radiation exposure, surgical smoke, working conditions and physical demands, sharps injuries, anesthetic gases and the use of toxic agents.
Smartphone data can help surgeons understand a patient's recovery
Surgeons report that they can describe the impact of certain postoperative events in their patients by capturing passively collected accelerometer data from a patient's smartphone.
Female surgeons earned 24% less per hour while operating compared to male surgeons: study
Female surgeons earned 24 per cent less per hour while operating compared to male surgeons, finds a new study led by St.
Earnings disparities between female, male surgeons in Canada
Female surgeons in Ontario, Canada, earned less per hour than their male counterparts within a fee-for-service system, and women were less likely to perform the most lucrative procedures.
New probe could help surgeons more accurately remove tumours
A study led by researchers at RCSI's Department of Chemistry has the potential to help surgeons more accurately remove tumours and detect cancer in lymph nodes during surgery.
Factors orthopaedic surgeons should consider when prescribing opioids
Orthopaedic surgeons are the third-highest physician prescribers of opioids, writing more than 6 million prescriptions a year.
Patients of surgeons with unprofessional behavior more likely to suffer complications
Patients of surgeons with higher numbers of reports from co-workers about unprofessional behavior are significantly more likely to experience complications during or after their operations, researchers from Vanderbilt University Medical Center (VUMC) reported today in JAMA Surgery.
More Surgeons News and Surgeons Current Events

Trending Science News

Current Coronavirus (COVID-19) News

Top Science Podcasts

We have hand picked the top science podcasts of 2020.
Now Playing: TED Radio Hour

Listen Again: Meditations on Loneliness
Original broadcast date: April 24, 2020. We're a social species now living in isolation. But loneliness was a problem well before this era of social distancing. This hour, TED speakers explore how we can live and make peace with loneliness. Guests on the show include author and illustrator Jonny Sun, psychologist Susan Pinker, architect Grace Kim, and writer Suleika Jaouad.
Now Playing: Science for the People

#565 The Great Wide Indoors
We're all spending a bit more time indoors this summer than we probably figured. But did you ever stop to think about why the places we live and work as designed the way they are? And how they could be designed better? We're talking with Emily Anthes about her new book "The Great Indoors: The Surprising Science of how Buildings Shape our Behavior, Health and Happiness".
Now Playing: Radiolab

The Third. A TED Talk.
Jad gives a TED talk about his life as a journalist and how Radiolab has evolved over the years. Here's how TED described it:How do you end a story? Host of Radiolab Jad Abumrad tells how his search for an answer led him home to the mountains of Tennessee, where he met an unexpected teacher: Dolly Parton.Jad Nicholas Abumrad is a Lebanese-American radio host, composer and producer. He is the founder of the syndicated public radio program Radiolab, which is broadcast on over 600 radio stations nationwide and is downloaded more than 120 million times a year as a podcast. He also created More Perfect, a podcast that tells the stories behind the Supreme Court's most famous decisions. And most recently, Dolly Parton's America, a nine-episode podcast exploring the life and times of the iconic country music star. Abumrad has received three Peabody Awards and was named a MacArthur Fellow in 2011.