Peeking Behind the Curtain : Surgical Judgement Beyond Cognition
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Transcript of Peeking Behind the Curtain : Surgical Judgement Beyond Cognition
Behind The Curtain S u r g i c a l J u d g m e n t B e y o n d C o g n i t i o n
Carol-Anne Moulton, MBBS, MEd, PhD, FRACS
I am notcut out to do this
Surgical Judgment
Moulton et al. (2007)
Slowing DownWhen You Should
Attention Threshold
Novice
Primary activity
Spare capacity
Expert
Primary activity
Spare capacity
Kahneman (1973)
Attention Threshold
Effortful
Primary activity
Spare capacity
Automatic
Primary activity
Spare capacity
Slowing Down
T h e Moment
Slowing Down
“…my efforts during these moments of crises were
consumed with the anxiety I was feeling and
intermixed with feelings of inadequacy, uncertainty,
reputation and ego.”Senior Surgeon, Interview
The Unspoken
Qualitative
Charmaz (2000)
Reflecting on Individual Factors in Surgical Adverse Events
Leung et al. (2012)
Un-AvowedAvowed Dis-Avowed
Ginsburg et al. (2003)
Avowed
Avowed
“I gave the patient a stoma. He didn’t
want one but I really felt it was the best
thing to do, the safest thing to do for
him.”
(IV-401)
Un-Avowed
Un-Avowed
“I think the pressure of the clock is distracting
and you hurry things along...we know that it is
a wrong thing to operate by the clock but
we’re put in a position where we’re in some
ways forced to do that.”
(I-01)
Dis-Avowed
Dis-Avowed
“There are ones like, well, do I really
need this help, do I want to seem like a
loser, am I going to call someone?”
(I-25)
T h e Moment
“I remember all of my deaths . . .”
THE FALLSurgeons’ Reactions to Failure
Luu et al. In press.
Unique
UniqueY o u a r e n o t
“Absolutely there is.
No question in my mind.”
(I-011)
“Who sent you to me? Did you hear
that I am an outlier?”
(I-008)
“I can only speak on the outside,
but they appear to have stuff slide
off of them.”
(I-002)
“You didn’t think this bothered me
as much as it did right?
(I-009)
The
Kick
Tachycardia
“There’s tachycardia…and there’s
unease…anxiety.”
(I-019)
Imposter
“I’m not entitled to walk around
with my lab coat and my scrubs
and be a surgeon or a scientist or
whatever. You just feel personally
devalued.”
(I-005)
Failure
“You kind of want to hide, run away
and hide in the corner and be
alone.”
(I-003)
Emotional
“I almost crashed into four parked
cars before I got out of the parking
garage that day. I was so
distraught … like I am not a guy
that cries, but…”
(I-001)
Incapacitated
“So you’re dealing with the
emotional turmoil and that morbid
feeling of you’ve done something
bad and it generally incapacitates
you.”
(I-005)
The
Fall
Was it my fault?
“Did I goof something or did I miss
something? Is it a technical
problem? So I relive the operation
and I go through the critical parts
of the operation.”
(I-003)
The
Recovery
Short Term
“I’m going to learn from this. I’m not
going to dismiss it and say, “Well, it’s
the patient’s fault” or “It’s the nurse’s
fault”, sort of learn from it whatever
the problem was and move on.”
(I-003)
Short Term
“And you can get up or not. If you
don’t get up, that’s slow suicide or
termination of what you do for a
living.”
(I-008)
The
Impact
Long Term
“I think that each mistake I make, or
each complication I have, or each
patient I bury, I think has taken a
little wee piece out of me.”
(I-008)
Long Term
“It's that kind of obsessiveness on my side that's
aging me at an incredible rate…affects my
tolerance for taking chances… I get to a point
where there are fewer and fewer cases that I
get really excited about…like I see the very
negative side of it or the negative is starting to
outweigh the positive”
(N-009)
Reputation
“The truth is you’re also worried about
yourself. I think, really, you’re worried
about your reputation, how people are
going to think of you, the finger
pointing…everyone in the community is
going to know.”
(N-002)
Expectation
Surgical RealityExperience
Social Cognition
Constructed Identities
Pratt et al. (2006), Gergen & Davis (1985)
Constructed Identities
“So someone who’s knowledgeable,
confident, decisive, and walks with
their head held high. They have that
like strut, that like surgeon’s walk.”
(J-001)
Constructed Identities
“You’re not supposed to be afraid,
you’re supposed to be in control,
you’re supposed to know everything,
you’re supposed to be able to do it.”
(J-003)
Looking Glass Self
Cooley (1902)
Looking Glass Self
“And then I believe that now he believes that
I’m not a qualified surgeon to be doing this type
of operation if I still make those mistakes. But
then what happens in my mind is I believe that
we have to now sort of start from the beginning
in which we’ll do again more and more
operations and then he’ll eventually think that
I’m an okay surgeon, and then he’ll let me do it
by myself thereafter.”
P-008
Looking Glass Self
“You have to have the confidence that you
can do it. Everyone has to be on your side and
it’s got to be a can-do kind of thing, because if
it’s not, then people start to eat away at you.
They second guess you. Are you sure? Do you
want me to call? And then you get self doubt
and lose your confidence and then you can’t
do your job.”(J-003)
Performativity
Goffman (1959)
Performativity
“It was a horrible case. And I couldn't identify the
rectum. I couldn't even identify the sigmoid...So I'm
operating with the senior resident and thinking to
myself, I'm a colorectal staff…and I can't even identify
the rectum...I'm not saying it to anyone else in the
Operating Room. I'm like, God. I'm like giving the
perception that I can tell what's going on here...I think I
must have spent a lot of time doing nothing...During
that time in the OR there's probably very minimal going
on in terms of actual operative patient care. It was like
taking care of myself…”
(K-
23)
Socialization
Hafferty (1991), Cassell (1991)
Socialization
“...when I presented my case they laughed...as soon as one
laughs then the other laughs...and no one has the balls to not
laugh. It's almost like a little club...I'm thinking, does anybody
have the nerve to not conform?...No one wants to be the
dumbest… no one wants to be the least informed, or the most
inquisitive. It's almost like when you have the big shots all
together you can't really be inquisitive, and if you're inquisitive
people laugh at you.”
(K-3)
Primary activity
Pressures to
Measure Up
Cognitive Capacity
Jin, et al. Ann Surg, 2013
“…And then the staff showed up just outside the
operating room to see how things were going, and I
can see the fellow getting completely nervous and
then completely changing and telling me “go faster”,
“come on, you have to grab it”, when beforehand we
were just going at a normal sort of slow pace... he got
nervous, to the point that we ended putting the kidney
upside down. So we had to take all the stitches out,
and put it back in again. ”
(P008)
Cognitive Capacity
Towards a More Mindful
SurgeonEpstein et al. (2008)
Towards a Surgical Decision
Vocabulary
Towards Surgeon
Wellness
Tools for building a different
Surgical Culture
Ministry of Research and Innovation Early Researcher Award
Royal College of Physicians
and Surgeons of CanadaMedical Education Research Grant
Physicians Services IncorporatedHealth Professional Research Grant
Behind The Curtain S u r g i c a l J u d g m e n t B e y o n d C o g n i t i o n
Glenn RegehrHelen MacRaeLorelei LingardSteven GallingerAnnie LeungShelly LuuJenny JinNathan ZilbertPriyanka PatelLaurent St. Martin
Simon KittoTina MartimianakisJacob GallingerLucas MurnaghanSandra deMontbrunTulin CilVicki LeBlancLisa Mark Carween MuiShira Gold