The role of decision skills and medical knowledge in the clinical judgment of surgical residents.

Five surgical management problems amenable to solution by decision analysis were developed to test the decision-making skills, or surgical judgment, of residents in three university-based surgical training programs. Incorporated within the problems were indicators of textbook knowledge, basic computational ability and the ability to integrate probabilistic information in a logical decision-making process. Seventy-two residents representing 65% of those in the 5-year programs participated. Correct answers were determined by 50 senior surgeons and independently supported by the surgical literature and decision analyses. The percentage of correct surgical decisions averaged 72 +/- 3% until after the chief residency year, when it rose to 87 +/- 6%. Among the residents still in training, correct clinical decisions were associated with more accurate estimates of textbook information. The clinical recommendations of senior surgeons were consistent with the solutions of the problems by formal decision analysis in 92 +/- 2% of cases; the clinical recommendations of residents were consistent in 77 +/- 2% of cases. Decision analyses with appropriate use of textbook information could improve the accuracy of the residents' clinical recommendations. Decision analysis without accurate information resulted in inferior decision making for one of the management problems. Decision analysis can supplement, but not replace, the acquisition of scientific knowledge in the education of surgical residents.