Rutkow I M, Gittelsohn A M, Zuidema G D
Ann Surg. 1979 Sep;190(3):409-19. doi: 10.1097/00000658-197909000-00017.
Elective surgery second opinion programs are predicted on strict acceptance of the accuracy of the consultant's surgical judgment. The reliability and reproducibility of clinical judgment, therefore, become basic to the effectiveness of such programs. This aspect, however, has received little attention. We report a randomized and controlled survey of surgical specialists which defines agreement/disagreement patterns in surgical decision-making for seven elective surgical procedures. For each disease process, four case histories, including at least one control, were developed by specialty panels of physicians. The case summaries described fictional patients who were seeking professional consultation. The histories were mailed to a random sample of Board-certified specialists from the State of Maryland and the District of Columbia. The response rate was approximately 80% for all five specialties. The respondents were asked to indicate whether they would (Yes) or would not (No) perform the surgical procedure in question. Factual knowledge was not sought, but instead the application of that knowledge and experience to decide on the need for surgical intervention. By comparing the responses for each case history, the agreement/disagreement patterns of inter-observer surgical judgment were determined. Analysis of the data revealed a marked divergence of opinion concerning the need for surgery. The significant point of this study is that surgical judgment differs to a major degree from one surgeon to the next. In a second-opinion program the number of consultants needed to provide a reliable clinical decision probably exceeds the number who are logistically available and that the patient would be willing to visit. Surgical decision-making is a semi-exact scientific process, and it is unreasonable to expect exact answers to clinical problems.
选择性手术的二次诊断项目基于严格认可会诊医生手术判断的准确性。因此，临床判断的可靠性和可重复性成为此类项目有效性的基础。然而，这方面几乎未受到关注。我们报告了一项对外科专家的随机对照调查，该调查确定了七种选择性外科手术在手术决策中的一致/不一致模式。对于每个疾病过程，由医生专业小组编写了四个病例史，其中至少包括一个对照病例。病例摘要描述了寻求专业咨询的虚构患者。这些病例史被邮寄给马里兰州和哥伦比亚特区经委员会认证的专家的随机样本。所有五个专业的回复率约为80%。受访者被要求表明他们是否会（是）或不会（否）进行所讨论的外科手术。我们没有询问实际知识，而是询问如何将这些知识和经验应用于决定是否需要手术干预。通过比较每个病例史的回复，确定了观察者间手术判断的一致/不一致模式。数据分析显示，在是否需要手术方面存在明显的意见分歧。这项研究的重点是，不同外科医生的手术判断存在很大差异。在二次诊断项目中，要提供可靠的临床决策所需的会诊医生数量可能超过在后勤上可行且患者愿意就诊的数量。手术决策是一个半精确的科学过程，期望临床问题得到精确答案是不合理的。
