Under pressure: The surgeon's conundrum in decision making

July 9, 2018, Johns Hopkins University School of Medicine

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 , 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 : 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 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 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.

Explore further: Emergency treatment by older surgeons linked to slightly lower death rates

More information: Rachel S. Morris et al. Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective, Journal of the American College of Surgeons (2018). DOI: 10.1016/j.jamcollsurg.2018.01.008

Related Stories

Emergency treatment by older surgeons linked to slightly lower death rates

April 26, 2018
Patients undergoing emergency surgery who are treated by older surgeons (aged 60 or over) have slightly lower death rates in the first few weeks after their operation than patients treated by younger surgeons (aged less than ...

Surgeons have substantial impact on genetic testing in breast cancer patients who need it

July 3, 2018
For many women diagnosed with breast cancer, genetic testing can offer important information that might guide treatment choices. But studies have shown that only about half of women who could benefit receive genetic testing.

Support tool could aid decision on total joint arthroplasty

September 16, 2015
(HealthDay)—A decision-support tool would help with decision making for total joint arthroplasty (TJA) for patients with osteoarthritis, according to a study published online Sept. 8 in the Journal of Evaluation in Clinical ...

To operate or not to operate: A serious question with no clear answers

May 20, 2016
What goes into a surgeon's decision to operate or recommend an alternative treatment option?

Surgery practice patterns differ by location of residency

January 12, 2018
(HealthDay)—Nonuniversity-based residency (NUBR)-trained surgeons and university-based residency (UBR)-trained surgeons have distinct practice patterns, according to a study published online Jan. 10 in JAMA Surgery.

Surgeons emotionally affected by surgical complications

November 20, 2013
(HealthDay)—Many surgeons are profoundly emotionally affected by surgical complications, according to a study published in the December issue of the British Journal of Surgery.

Recommended for you

Surgical adhesions can be treated, prevented in mice

November 28, 2018
A cellular culprit—as well as a possible treatment—for a common, sometimes life-threating post-surgical complication has been identified by researchers at the Stanford University School of Medicine.

Cost and weight-loss potential matter most to bariatric surgery patients

November 28, 2018
A JAMA Surgery study found that patients are likely to base their weight loss surgery choice on expected out-of-pocket costs, and how much weight they can lose—not risk of complications or recovery time.

Treating spinal pain with replacement discs made of 'engineered living tissue' moves closer to reality

November 21, 2018
For the first time, bioengineered spinal discs were successfully implanted and provided long-term function in the largest animal model ever evaluated for tissue-engineered disc replacement. A new Penn Medicine study published ...

Screening for colorectal cancer spares male patients from intense treatments

November 21, 2018
While screening for colorectal cancer does not reduce mortality, it does reduce the need for chemotherapy and emergency surgeries among male patients, according to a recent Finnish study.

Rapid response inpatient education boosts use of needed blood-thinning drugs

November 16, 2018
A new study designed to reach hospitalized patients at risk shows that a "real-time" educational conversation, video or leaflet can lower the missed dose rates of drugs that can prevent potentially lethal blood clots in their ...

Race plays role in regaining weight after gastric bypass surgery

November 15, 2018
African Americans and Hispanic Americans who have undergone Roux-en-Y gastric bypass (RYGB) are at greater risk to regain weight as compared to Caucasians. To date, no study has addressed the effect of race on weight regain ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.