Department of Surgery, University of Toronto, Wilson Centre, Toronto, ON, Canada.
J Am Coll Surg. 2010 Jan;210(1):79-86. doi: 10.1016/j.jamcollsurg.2009.09.043.
Critical moments in operations cause the surgeon to transition from a relatively "automatic" mode of operating to a more attentive mode-previously referred to as "slowing down when you should." Using this framework, this study explored how academic surgeons manage and balance the often competing responsibilities of patient safety and education during the slowing-down moments.
This study used a constructivist approach to grounded theory methodology to explore an emergent theme of control among academic surgeons. Twenty-eight surgeons were interviewed across 4 academic teaching hospitals, and 5 general (hepato-pancreatico-biliary) surgeons were observed. Thematic analysis of the transcripts and field notes was conducted and iteratively elaborated and refined as data collection progressed with all team members. A reflexive approach was adopted throughout.
An interesting control dynamic emerged as surgeons discussed the need to maintain a sense of control of an operation regardless of how much manual control they had. A dual responsibility to education and patient safety was apparent, with surgeons describing and demonstrating numerous strategies for negotiating manual control with the trainee during the critical slowing-down moments. An assessment of the trainee was implicit in the negotiation process. Numerous complications of control were identified ("bargaining," "skidding") as a product of this control dynamic.
Operating from the "other side of the table" sets up a control dynamic that requires manipulation and negotiation on the part of the academic surgeon. Understanding these issues informs surgeons in their supervisory role, offering avenues for optimizing surgical training.
手术过程中的关键时刻会促使外科医生从相对“自动”的操作模式转变为更加专注的模式——此前称为“应该减速时减速”。基于这一框架，本研究探讨了学术外科医生在减速时刻如何管理和平衡患者安全和教育这两项往往相互竞争的职责。
本研究采用建构主义方法对扎根理论方法进行探索，以研究学术外科医生之间的控制这一新兴主题。在 4 家学术教学医院对 28 名外科医生进行了访谈，并对 5 名普通（肝胆胰）外科医生进行了观察。对转录本和现场记录进行了主题分析，并随着数据收集的进行，由所有团队成员进行迭代阐述和完善，同时采用了反思方法。
随着外科医生讨论需要保持对手术的控制感，无论他们对手术的手动控制程度如何，一个有趣的控制动态出现了。教育和患者安全的双重责任显而易见，外科医生描述并展示了许多在关键减速时刻与学员协商手动控制的策略。对学员的评估是协商过程中的一个隐含因素。控制的许多并发症（“讨价还价”、“失控”）被认为是这种控制动态的产物。
从“桌子的另一边”操作会建立起一种控制动态，这需要学术外科医生进行操纵和协商。了解这些问题可以为外科医生的监督角色提供信息，为优化手术培训开辟途径。
