Decision Making in Surgery

“Do we need to be told what is right” - Plato[1] Anything pursuing perfection or precision is embellished, with medicine as an adjective i.e. precision medicine, or clinical precision. Practice of surgery, commands, an higher embellishment, putting the burden of attendant demand, on the surgeon. That is why, when we are called to tackle the root of an undesirable process or an event, it is described as ‘Surgical Strike’ or ‘Surgical Precision’. This experienced and expected performance imparts a natural credence to the trust in decision making skills of surgeon. However, we as surgeons are not immune to a paradoxical dilemma of our innate decision-making skills cohabiting with the anxieties of challenges that come with decision making in clinical scenario. Decision making is a cognitive process of choosing the best amongst many alternatives. At times, the best decision, a surgeon can take from amongst the alternatives, is the decision ‘not to operate’ i.e. inaction being the best course of action. Charles Bosk in his book ‘Forgive and Remember’ has said that surgical treatment links the action of our practice or our decision making to the patient’s response more intimately than any other aspect of medical specialties. He explains that the workplace reactions to unexpected or adverse outcomes differ with respect to a physician and a surgeon. When things go wrong with physician colleagues, they are asked “what happened?”. But when things go wrong, in practice of surgery, the surgeon is asked by his colleagues “what did you do?”[2] Hence, it is not wrong to say, that surgery leaves a scar on patient’s mind, patient’s body and potentially on surgeon’s mind to carry as well.[3] It becomes incumbent for us to think not what best that we can do, but what is the best that should be done for the patient.[4-6] Like anything in existence, decision making in given circumstances involves a process of various steps which are:[7] 1) Identifying the problem, 2) Gathering relevant information e.g., taking a good clinical history, doing good clinical examination including targeted local examination, 3) Identify the alternatives- Sifting the information mentally in view of the education and training that we have received and identify the alternatives to deal with the situation, 4) Sifting through evidence- go back and look at the evidence available and sifting through all the evidence available, 5) Weigh the alternatives, their pros and cons, the advantages and disadvantages of outcomes associated with different alternatives, 6) Review the process- Visual Mental Rehearsal (VMR), the way ahead- do a VMR. It is a standard technique employed in training of Olympic athletes, where they are trained to visualize their performance from the beginning till the winning line, 7) Take action - after visualizing the potential outcomes following various alternatives and especially the alternative that we have thought best, start to take an action. However, none of these steps is important in its absoluteness.[8] All of them or none of them may become handy in difficult situations. Hence, it is important to remember that it is the mean or the average of all of the above steps entertained that may provide a solution. Just like a portfolio approach in our daily life, when we make decisions about finances and keep some money in banks, some in stocks, some in mutual funds, some in assets like gold or property and some for emergencies. Decision making thus involves a complex mental processing which can be based upon two things,[9,10] 1) Pattern recognition- an intuitive process. It is subconscious. It is based upon our beliefs, which themselves are based on experience and heuristics. They appear to be contextual and automatic. Hence they conserve less mental energy and come promptly to our mind, given the pattern that we have recognized from our experience of dealing with similar situations quite frequently and presentation not showing any deviation from those predefined patterns e.g. classical case of appendicitis comes to our mind whenever there is a presentation without any deviation i.e. periumbilical pain or central abdominal pain associated with nausea, vomiting and loss of appetite and pain migrating and settling down in lower abdomen, usually to the right side and followed by symptoms and signs of localized or evolving peritonism. 2) Analytical mental processing - This comes into play when the presentation is not so classical or it’s not fitting into a standard pattern, although there may be different components with some deviation here and there in one or more of the components. The analytical mental processing requires logic and reasoning. It requires revisiting concepts and applying a deductive knowledge to filter down the possibilities. Hence, it is slow and consumes lot of mental capacity. The decision making processes can be helped or complicated by evolution in things like technology, evidence, social reforms like accountability and auditing and working in multidisciplinary teams. However, just like portfolio approach described above, all these factors can play a positive role if a concept of POEM is kept in mind i.e. whatever information we gather, whatever analysis we make, whatever technology, evidence or multidisciplinary advice we consider, the most important thing is Patient Oriented Evidence Matters (POEM) alone.[11] Despite the complexities involved in decision making in surgical practice, it has been made structured and somewhat easier with some of the developments in medical science. In surgical practice, most important of these is “informed consent.”[12-15] Informed consent not only educates the patient but also makes patient a partner in decision making and hence, minimizing the ‘expectation - outcome gap’. Informed consent classically involves educating the patient about his clinical presentation being consistent with the medical diagnosis, the treatment options for the entertained medical diagnosis, the alternatives for treatment, with respect to their respective advantages and disadvantages, in terms of expected outcomes. The best outcome chosen and it’s expected clinical outcomes including complications. Informed consent involves, describing in layman terms the steps of the chosen surgical procedure explained with expected post-operative clinical pathway and expected clinical outcomes including complications. The process of informed consent makes the decision-making easier to be put into practice because it helps in reducing the ‘expectation - outcome gap’. Another evolution in practice of surgery that has made decision-making more structured and surgery safer as a practitioner and as the patient both, is team approach or systems approach. The systems approach has been adopted by surgeons taking the airline industry experience. In airline industry, the pilot of a plane has to verbalize and get a consent of his co-pilot for every step, minor or major, that he undertakes while navigating airplane. In surgical practice, it extrapolates to the operating surgeon verbalizing every step that he is doing and completing the step only after a verbal accent from his team members. Hence the team approach or systems approach. Sometimes in practice, there is nothing new. The presentation is classical, the findings are classical and the investigation results are also concurrent with the clinical presentation and clinical diagnosis. However, they are sometimes taken to surprise by common sense. As the poet, TS Eliot said, ‘the business of the poet is not to find new emotions, but to use the ordinary ones and working them up into poetry’. So this poetic approach and the POEM approach, at times can surprise us. For example, I have come across a couple of patients like the one I am describing here. A girl 24 years of age married for a year, presented to my clinic with history consistent with Obstructive Defecatory Syndrome (ODS), with a significant ODS score, not improving despite a progressively encouraging laxative cocktail. She was evaluated by a gastroenterologist and a surgeon colleague, has had colonoscopy, transit study, rectal manometry and defecography, the later pointing towards rectocele and recto-rectal intussusception. She was referred to me for a Stapled Trans Anal Rectal Resection (STARR)/laparoscopic ventral mesh rectopexy. While she was talking to her husband, there seemed to be some disagreement, and the husband said ‘you always complain of your problem when you are with me, but not when you are with your parents’. When enquired, the girl told me that she has these symptoms of constipation only when she is at her husband’s house, and she is ‘so totally symptom -free’, when she is at her parents’ house. So common sense at times comes into play and tells us, that besides all the medical teaching and training and skills, upgradation with technology, we need to understand our patients socio-cultural construct, and strike a connect with her sociocultural mindset. In this era of technology, the things are evolving very fast in surgical practice because of introduction of a newer technology before the recently introduced technology has been fully adopted and incorporated in surgical practice.[16-18] This has led to what Abraham Maslow described as law of instrument, which is that an instrument can induce a cognitive bias i.e. an over-reliance on a familiar tool or technology. Simply put, he said, if you have a hammer, you might treat everything as a nail [Figure 1]. The implication of this in our practice is that with new and newer technologies passing through our hands, we should be aware of this law of instrument and hammer and nail fixation. We should not think of treating any surgical condition with a particular surgical technology or mechanism but think which one is best for the patient.Figure 1: Law of Instrument: Maslow’s Hammer and Nail[ 19 ]We all have come across working in multidisciplinary teams (MDT), especially in colorectal surgery and oncosurgery. The MDT approaches have helped in making decisions for welfare of the patient and deciding protocols, since multiple modalities of medical specialties may be involved in treating a single condition. There are advantages of MDT, but it has also been reported that MDT can lead to shifting of responsibility and decisions which may not be in best interest of the patient.[20,21] As opposed to MDT, discussions about decision making in our core surgical teams are likely to be more precise, rational and directed towards patient benefit. Hence, just like portfolio approach described before, proper decisions should way the pros and cons of both MDT decisions and core team -based decisions. When it comes to core teams, it is said that when you are working in a TEAM, Together Everyone Achieves More. As a surgeon, we should be careful in identifying people with certain characteristics in our teams. We should be aware of members in our team who have what is known as Texas Sharpshooter Syndrome.[22] This syndrome is like the team leader shoots an arrow and the team member draws a target circle around that arrow irrespective of the arrow being on any part of the wall whether that was intended or not [Figure 2]. Such team members are just seconding your opinion and not contributing anything to decision making. Similarly there may be a team member who may be always well read and always eager to share the recently read knowledge and sharing it not for application in that current situation for benefit of the patient, but just jumping the gun to show his recently acquired knowledge.Figure 2: Texas Sharpshooter FallacyThis has been described as Dunning–Kruger effect, which means that the more ignorant a person in terms of application of knowledge, the more confident she sounds and vice versa [Figure 3].[23] To sum them up, we can see that a fool with a tool is still a fool. While we should be aware of the members having a Texas Sharpshooter Syndrome or Dunning–Kruger psychology, we should also be aware ofFigure 3: Dunning kruger effectMembers, who might be having what is known as Munich - Massacre syndrome i.e. we should not be afraid of failures. The practice of surgery will always have some experiences that did not go as per expectations and failed. When the Israeli team was massacred in Munich, the Israel citizens suffered from delusions for quite a long time, looking at any hooded person as a potential murderer, hence the name Munich Massacre Syndrome.[24] Given this multitude of variables involved in decision making, a portfolio approach thus comes handy. At times what seems to be simplest explanation usually is the best one as is known by the name Occam’s Razor. It was used by our forefathers, Halstead and Ostler when they will tell their residents ‘When in Texas, if you hear hoofs, think of horses, not zebras’. To put it very simply, a team member falling in the description of Dunning and Krueger when faced with the classical symptoms of acute appendicitis with tenderness in lower abdomen, more on the right side and the member is eager and jumps on with an explanation. What if he has situs inversus? The tenderness should be more on the left side. While the above is general process of decision making in any situation, in clinical science, we should never forget this classical seven-step surgical crescendo in making decisions i.e. 1) History and a general observation of the patient 2) Clinical examination 3) Mental sifting through knowledge of anatomy, physiology and pathologies 4) Differential diagnosis - a mental process of exclusion or reinforcement 5) Biochemical, bacteriological, radiological, sonographic or nuclear investigations. 6) Accessible parts scoped- upper/lower GI endoscopy, cystoscopy etc. 7) Diagnostic intervention/laparoscopy/biopsy etc. In this era of evidence -based medicine, structured teaching, training and skilling programs, protocols and checklists, sometimes the decisions are not easy to come by. The scenario is further complicated by people having propensity to parrot convenient part from the evidence, making he process rather eminence based. We as surgeons should remember that we do what is best for the patient, and while doing so, we should try to do our best. We should have faith in our abilities and decisions taken, and remember that human error is inherent part of practice of any profession. However, errors may be consequential or inconsequential, as explained, by James Reason.[25] When he described that our actions are hazardous only when, like an arrow, they pass through perfectly aligned holes of a series of continuously revolving cheese slices [Figure 4].Figure 4: Reason’s model of consequential errorsSurgical practice is unique in demanding the surgeon to have strong intuition and be innovative, because every surgical finding in a similar diagnosis may have some variation. It was thought that intuition comes naturally, it is inherent. But now it has been shown that intuition is nothing but a combination of knowledge, ability, endurance, intellect, discourse and memory. It is also said that intuition can be learned and people can be schooled in it.[26,27] All these qualities that give rise to intuition eventually are also linked to what is demanded of surgeon at times, i.e. ‘Out of box thinking’. Out of box thinking is nothing but a phrase that came out from a riddle which asked to connect nine dots in a square with a single continuous line. With best of the efforts, it is not possible unless the line is taken out of the square box [Figure 5].Figure 5: Out of box thinkingIntuition, out of the box thinking and imagination are the defining characteristics of a surgeon. It has been said that a surgeon should be an imagination driven engineer. A surgeon should be I-Innovative, M-molecular science, understands the molecular basis of disease, A- ancient wisdom understands the socio -cultural background of the patient and connects with that, G –genetic, understands genetics and embryology, thus knowing the anatomy and embryological planes of fusion helping the surgeon and surgical navigation, I- imaging and information technology - utilizes the current developments in imaging and technology to fullest, N-Nano technology is not afraid of miniaturization and R – Robotics. So, the surgeon should be imagination -driven engineer i.e., Imagineering.[1] The surgeons of future will have to be, as has, always been the case, PROF- patient reported outcome friendly. In an era of ERAS, enhanced recovery after surgery, we have to be TEAM (together, everyone achieves more) oriented, practice POEM (practice patient -oriented evidence, matters alone) and aspire to resume our patients‘ activity, bath, commitments, diet, exercise, and family life (ABCDEF), within two to three days of surgical intervention. We have to remember that future lies with the next generation. We have to pass on our skills, training, and succsses with failures in decision-making, to the next generation. Because our primary responsibility is to try and produce our own replacements i.e., surgeons who are better than us.[28] We should not be worried about whether our actions or innovations be liked by fraternity, as long as they are in interest of the patient. As has been said by Max Planck ‘New scientific truth doesn’t triumph by persuading its opponents and status quoists but rather by opponents gradually dying out and giving way to a new generation that is raised on it’. When it comes to young generation, we know they are better than us in adoption and rapid assimilation of technology. Hence, we should not be afraid of sharing our skills with them and training them, as well as learning from them the new skills from the new technology as is said that “old dog should teach the new dog his skills, and old dog should learn new tricks from the young dog”.[29] The choice is ours whether we leave a legacy of better replacements than ourselves, or we just work towards material metrics of success and progress. Even if we make an iota of betterment in our next generation, we would have done our job well, because we know from British cycling team experience that small percentages aggregate to a major gain known as theory of aggregation of marginal gains.[30] While decision making may sound to be a complex process, but most of the times it comes easy given our teachers who have imparted their skills to us and our interactions with our youngsters with the commitment to train of a structured training for decision making skills, is to good making decisions and not so in to make make good decisions. I all my residents to three i.e., The and They are a good to learn about and despite of surgical and socio -cultural common sense having a role in medical practice