From U Toronto: "First, Do No Harm": Balancing Competing Priorities in Surgical Practice

http://www.ncbi.nlm.nih.gov/pubmed/22914525

Acad Med. 2012 Aug 21. [Epub ahead of print]

"First, Do No Harm": Balancing Competing Priorities in Surgical Practice.

Leung A, Luu S, Regehr G, Murnaghan ML, Gallinger S, Moulton CA.

Source

Ms. Leung is a fourth-year medical student, University of Toronto Faculty of Medicine, and research assistant, Wilson Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada. Ms. Luu is a fourth-year medical student, University of Toronto Faculty of Medicine, and research assistant, Wilson Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada. Dr. Regehr is the associate director, Centre for Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada. Dr. Murnaghan is an orthopaedic surgeon, Hospital for Sick Children, and assistant professor, Department of Surgery, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada. Dr. Gallinger is head of the hepatobiliary/pancreatic surgical oncology program and codirector, Zane Cohen Digestive Diseases Centre, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada. Dr. Moulton is a hepatobiliary/pancreatic surgeon, University Health Network, and scientist, Wilson Centre, University of Toronto, Toronto, Ontario, Canada.

Abstract

PURPOSE:

To explore surgeons' perceptions of the factors that influence their intraoperative decision making, and implications for professional self-regulation and patient safety.

METHOD:

Semistructured interviews were conducted with 39 academic surgeons from various specialties at four hospitals associated with the University of Toronto Faculty of Medicine. Purposive and theoretical sampling was performed until saturation was achieved. Thematic analysis of the transcripts was conducted using a constructivist grounded-theory approach and was iteratively elaborated and refined as data collection progressed. A preexisting theoretical professionalism framework was particularly useful in describing the emergent themes; thus, the analysis was both inductive and deductive.

RESULTS:

Several factors that surgeons described as influencing their decision making are widely accepted ("avowed," or in patients' best interests). Some are considered reasonable for managing multiple priorities external to the patient but are not discussed openly ("unavowed," e.g., teaching pressures). Others are actively denied and consider the surgeon's best interests rather than the patient's ("disavowed," e.g., reputation). Surgeons acknowledged tension in balancing avowed factors with unavowed and disavowed factors; when directly asked, they found it difficult to acknowledge that unavowed and disavowed factors could lead to patient harm.

CONCLUSIONS:

Some factors that are not directly related to the patient enter into surgeons' intraoperative decision making. Although these are probably reasonable to consider within "real-world" practice, they are not sanctioned in current patient care constructs or taught to trainees. Acknowledging unavowed and disavowed factors as sources of pressure in practice may foster critical self-reflection and transparency when discussing surgical errors.