What’s New in the Patient Safety World

October 2011

Surgeons’ Mode of Intraoperative Decision Making



We’ve done several columns talking about the way physicians make decisions and how decisions are made in other industries. Our May 29, 2008 Patient Safety Tip of the Week “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work” focused on pattern recognition and recognition-primed decision making that typically takes place in more acute scenarios. Our August 12, 2008 Patient Safety Tips of the Week “Jerome Groopman’s “How Doctors Think” and September 28, 2010 “Diagnostic Error” focused on the work of Jerry Groopman, Gordon Schiff, and others demonstrating how various processes are involved in physicians’ thinking in diagnostic situations. And our October 12, 2010 Patient Safety Tip of the Week “Slowing Down in the OR” discussed how surgeons refocus their attention at critical times during surgical procedures.


Now a new study (Pauley 2011) of surgeons’ mode of intraoperative decision making shows that surgeons in urgent situations are split about equally between the rapid recognition-primed and the analytical method where multiple potential responses are compared. Moreover, the type of decision making used was not associated with the type of operation, the context (emergency vs. elective), or the time pressures involved. The authors also looked at how surgeons perceived risk or threats in each case (risk assessment), managed risk, and what their risk tolerance was. The degree of risk assessment did depend on the decision making strategy used. For example, in the more intuitive rapid recognition-primed method they assessed the risk of the single action chosen, whereas in the more analytical method they assessed the risk of multiple choices. They summarize that decision making and risk assessment and management likely reflect many of the individual surgeon’s personality traits.


These findings contrasted with prior work (Flin 2007) by the same authors. In that work the authors had suggested surgeons should or would adopt strategies similar to those used by pilots for in-flight decision making. In the current study their predictions did not bear out. They ascribe the difference to the fact that pilots generally have only seconds in which to arrive at their decisions whereas surgeons, in most circumstances, have a longer timeframe within which to assess the situation, assess risks, and decide on a course of action. Nevertheless, you’ll find the 2007 paper by Flin et al to be useful reading.


The “science” of how we think and make decisions in various scenarios is fascinating. But it is also important in our learning how to use various approaches to solve problems and how some of the same processes can lead to bad outcomes in other circumstances.






Pauley K, Flin R, Yule S, Youngson G. Surgeons' intraoperative decision making and risk management. American Journal of Surgery 2011; 202(4): 375-381




Flin R, Youngson G, Yule S. How do surgeons make intraoperative decisions? Qual Saf Health Care 2007; 16(3): 235–239













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