First, Do No Harm Balancing Competing Priorities in Surgical Practice Annie Leung Shelly Luu Glenn Regehr M Lucas Murnaghan Steven Gallinger Carol-Anne Moulton
I have no actual or potential conflict of interest in relation to this presentation. Disclosure Statement
A Moment
We were doing a laparoscopic colon resection. She [the resident] was mobilizing the sigmoid, which was more fibrotic because of previous surgery. I remember in my mind thinking she s going too fast, I should take over, but I didn t want to because I wanted to give her a chance to get to do it. I was in a stage where my goal was to let the residents do as much as possible (I20) A Moment
I remember when I looked at it, before I could open my mouth, I was like crap, that s the ureter. She divided the ureter and you could see it. It was 20 seconds where she was just maybe off the wrong plane and I was trying to give her feedback and 5 seconds where I was getting ready to say here let me show you, but it was too late. (I20) A Moment
A Moment and the Decision
SchÖn s Reflective Cycle Reflection-on-action Knowing-in-action Reflection-in-action Schön s Cycle of Reflection Donald Schön The Reflective Practitioner: How Professionals Think in Action
Constructivist Grounded Theory Semi-Structured Interviews, 39 Surgeons General 18, Neurosurgery 4, Orthopaedic 4, Cardiac 3, Vascular 3, Thoracic 2, Otolaryngology 2, Plastics 2, Trauma 1 Methods
Personal Complications errors and/or adverse events Methods
Factors that influence intra-operative decisions Methods
Analysis: Inductive & Deductive Grounded Theory Professionalism Framework Methods Ginsburg S, Regehr G, Lingard L To be and not to be: the paradox of the emerging professional stance. Med Educ 2003;37:350-7
Decision Making feels like
...They all say the patient who is asleep at the time has your undivided attention but they don t... there are time pressures, nursing pressures, anaesthesia...you re not working in isolation. (I17) Decision making feels like...
Avowed Unavowed Disavowed Ginsburg s Framework Ginsburg S, Regehr G, Lingard L To be and not to be: the paradox of the emerging professional stance. Med Educ 2003;37:350-7
Avowed Patient s best interest e.g. first do no harm ideals of the profession
With his [the patient s] cardiac history, I decided a quick operation is a good operation, and didn t let the resident do much. (I22) Avowed
Unavowed Unacknowledged Undeclared e.g. time pressure teaching
I think the pressure of the clock is distracting and you hurry things along...we know that it is a wrong thing to operate by the clock but we re put in a position where we re in some ways forced to do that. (I1) Unavowed
Disavowed Denied, Discouraged, Inconsistent with professionalism e.g. monetary incentives concern for personal reputation
There are ones like, well, do I really need this help, do I want to seem like a loser, am I going to call someone? (I25) Disavowed
Avowed Unavowed Disavowed Ginsburg s Framework
Surgeon: I accept little imperfections because I think that they don t matter and I think that residents obviously have to learn... Interviewer: So you allow for some imperfections in how it looks or how it s carried out but you re monitoring how far it goes away from where it should. The Tension
Surgeon: Right, and I wouldn t let someone divide a tumour just let them learn about it, that s not what I mean. Interviewer: So you said you wouldn t let them divide a tumour but you let them divide a ureter. I m being the devil s advocate here. So how does that? The Tension
Surgeon: No, what I mean by letting them divide the ureter... I wouldn t let them do that it s just I didn t, like The problem was in that moment everything happened so fast. If I thought hey, there was a chance that she might injure the ureter I guess I did kind of think it but I thought that by coaching here I could avoid it. The Tension
Do No Harm vs. Surgical Reality
Mindful Practice Epstein RM Mindful Practice. JAMA 1999. 282(9):833-9
SLOWING DOWN WHEN YOU SHOULD: The Key to Expert Judgement Patient Safety
Surgical Education
The Culture of SURGERY You re not supposed to be afraid. You re supposed to be in control. You re supposed to know everything. You re supposed to be able to handle it. (J003) Surgeon as a Performer Jin CJ, Martimianakis MA, Kitto S, Moulton CA Pressures to Measure Up in Surgery. Ann. Surg. 2012 Jul 20
Thank You Jenny Jin Nathan Zilbert Shira Gold Jacob Gallinger Sandra de Montbrun Tulin Cil Doug Buller Ministry of Research and Innovation Early Researcher Award Royal College of Physicians and Surgeons of Canada Medical Education Research Grant University of Toronto Faculty of Medicine Comprehensive Research Experience for Medical Students Summer Scholarship