Dr. Cristancho is assistant professor, Department of Surgery, Department of Medical Biophysics, and scientist, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Mr. Apramian is research associate, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Dr. Vanstone is assistant professor, Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada. Dr. Lingard is professor, Department of Medicine, and director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Dr. Ott is assistant professor, Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Dr. Novick is professor, Division of Cardiac Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.
Acad Med. 2013 Oct;88(10):1516-21. doi: 10.1097/ACM.0b013e3182a3116f.
In clinical settings, uncertainty is part of everyday practice. However, a lack of insight into how experts approach uncertainty limits the ability to explicitly teach and assess it in training. This study explored how experienced surgeons perceived and handled uncertainty during challenging intraoperative situations, to develop a theoretical language supporting both education and research.
This constructivist qualitative study included observations and interviews during 26 surgical cases. The cases, drawn from seven staff surgeons from various specialties at a medical school, were purposively sampled after being preidentified by the surgeon as "likely challenging." The authors combined template and inductive analyses. In template analysis, an existing theory was used to identify instances of uncertainty in the dataset. Inductive analysis was used to elaborate and refine the concepts.
Template analysis confirmed that existing theoretical concepts are relevant to surgery. However, inductive analysis revealed additional concepts and positioned existing concepts within new relationships. Two new theoretical themes were recognizing uncertainty and responding to uncertainty, each with corresponding subthemes. Factors such as the novelty of the situation, difficulty in predicting the outcome, and difficulty deciding the course of action mainly characterize an uncertain situation in surgery according to the participants.
The results offer a refined language for conceptualizing uncertainty in surgery. Although further research could elaborate and test the explanatory power of this language, the authors anticipate that it has implications both for current discussions of surgical safety and for future development of explicit training for effective management of surgical uncertainty.
在临床环境中，不确定性是日常实践的一部分。然而，由于缺乏对专家如何处理不确定性的深入了解，限制了在培训中明确教授和评估不确定性的能力。本研究旨在探讨经验丰富的外科医生在面临挑战性手术情况时如何感知和处理不确定性，以开发一种支持教育和研究的理论语言。
本研究采用建构主义定性方法，在 26 例手术中进行观察和访谈。这些案例来自医学院的 7 位不同专业的主治外科医生，在被外科医生预先确定为“可能具有挑战性”的情况下进行了有目的抽样。研究人员结合了模板分析和归纳分析。在模板分析中，使用现有理论来识别数据集中的不确定性实例。归纳分析用于详细说明和完善概念。
模板分析证实了现有理论概念与外科手术相关。然而，归纳分析揭示了额外的概念，并将现有概念置于新的关系中。两个新的理论主题是识别不确定性和应对不确定性，每个主题都有相应的子主题。根据参与者的说法，情况的新颖性、预测结果的难度以及难以决定行动方案等因素主要构成了手术中的不确定情况。
研究结果为外科手术中不确定性的概念化提供了更精细的语言。尽管进一步的研究可以详细阐述和测试这种语言的解释力，但研究人员预计，它不仅对当前关于手术安全性的讨论具有影响，而且对未来开发有效管理手术不确定性的明确培训也具有影响。
