University of Toronto Faculty of Medicine, Department of Surgery, Wilson Centre, University Health Network and University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
Acad Med. 2012 Oct;87(10):1368-74. doi: 10.1097/ACM.0b013e3182677587.
To explore surgeons' perceptions of the factors that influence their intraoperative decision making, and implications for professional self-regulation and patient safety.
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.
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.
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.
探讨外科医生对影响其术中决策的因素的看法，以及对专业自律和患者安全的影响。
在多伦多大学医学院附属医院的四家医院，对来自不同专业的 39 名学术外科医生进行了半结构化访谈。采用目的性和理论性抽样，直到达到饱和。使用建构主义扎根理论方法对转录本进行主题分析，并随着数据收集的进行进行迭代阐述和完善。预先存在的专业主义理论框架对于描述新兴主题特别有用；因此，分析既具有归纳性又具有演绎性。
外科医生描述的一些影响其决策的因素是被广泛接受的（“公开宣称的”，或符合患者的最佳利益）。有些因素被认为是管理患者以外的多个优先事项的合理因素，但并未公开讨论（“未公开宣称的”，例如教学压力）。其他因素则被积极否认，并考虑到外科医生的最佳利益而不是患者的利益（“否认的”，例如声誉）。外科医生承认在平衡公开宣称的因素与未公开宣称的和否认的因素之间存在紧张关系；当被直接问及，他们发现很难承认未公开宣称的和否认的因素可能导致患者受到伤害。
一些与患者无关的因素会进入外科医生的术中决策。尽管这些因素在“现实世界”实践中可能是合理的，但它们在当前的患者护理结构中没有得到认可，也没有向受训者教授。承认未公开宣称的和否认的因素是实践中的压力源，可能有助于在讨论手术错误时进行批判性自我反思和透明度。
