Skip to main content
Annals of Surgery logoLink to Annals of Surgery
. 1979 Sep;190(3):409–417. doi: 10.1097/00000658-197909000-00017

Surgical Decision Making: The Reliability of Clinical Judgment

Ira M Rutkow, Alan M Gittelsohn, George D Zuidema
PMCID: PMC1344682  PMID: 485616

Abstract

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.

Full text

PDF
409

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bombardier C., Fuchs V. R., Lillard L. A., Warner K. E. Socioeconomic factors affecting the utilization of surgical operations. N Engl J Med. 1977 Sep 29;297(13):699–705. doi: 10.1056/NEJM197709292971305. [DOI] [PubMed] [Google Scholar]
  2. Brook R. H., Appel F. A. Quality-of-care assessment: choosing a method for peer review. N Engl J Med. 1973 Jun 21;288(25):1323–1329. doi: 10.1056/NEJM197306212882504. [DOI] [PubMed] [Google Scholar]
  3. Bunker J. P., Brown B. W., Jr The physician-patient as an informed consumer of surgical services. N Engl J Med. 1974 May 9;290(19):1051–1055. doi: 10.1056/NEJM197405092901905. [DOI] [PubMed] [Google Scholar]
  4. Bunker J. P. Surgical manpower. A comparison of operations and surgeons in the United States and in England and Wales. N Engl J Med. 1970 Jan 15;282(3):135–144. doi: 10.1056/NEJM197001152820306. [DOI] [PubMed] [Google Scholar]
  5. CONN H. O., MITCHELL J. R., BRODOFF M. G. A comparison of the radiologic and esophagoscopic diagnosis of esophageal varices. N Engl J Med. 1961 Jul 27;265:160–164. doi: 10.1056/NEJM196107272650402. [DOI] [PubMed] [Google Scholar]
  6. DAVIES L. G. Observer variation in reports on electrocardiograms. Br Heart J. 1958 Apr;20(2):153–161. doi: 10.1136/hrt.20.2.153. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. DENSEN P. M., JONES E. W., BALAMUTH E., SHAPIRO S. Prepaid medical care and hospital utilization in a dual choice situation. Am J Public Health Nations Health. 1960 Nov;50:1710–1726. doi: 10.2105/ajph.50.11.1710. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Detmer D. E., Tyson T. J. Regional differences in surgical care based upon uniform physician and hospital discharge abstract data. Ann Surg. 1978 Feb;187(2):166–169. doi: 10.1097/00000658-197802000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Edgahl R. H., Taft C. H., Friedland J., Linde K. The potential of organizations of fee-for-service physicians for achieving significant decreases in hospitalization. Ann Surg. 1977 Sep;186(3):388–399. doi: 10.1097/00000658-197709000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Gittelsohn A. M., Wennberg J. E. On the risk of organ loss. J Chronic Dis. 1976 Aug;29(8):527–535. doi: 10.1016/0021-9681(76)90016-3. [DOI] [PubMed] [Google Scholar]
  11. Grafe W. R., McSherry C. K., Finkel M. L., McCarthy E. G. The Elective Surgery Second Opinion Program. Ann Surg. 1978 Sep;188(3):323–330. doi: 10.1097/00000658-197809000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Hastings J. E., Mott F. D., Barclay A., Hewitt D. Prepaid group practice in Sault Ste. Marie, Ontario. I. Analysis of utilization records. Med Care. 1973 Mar-Apr;11(2):91–103. doi: 10.1097/00005650-197303000-00002. [DOI] [PubMed] [Google Scholar]
  13. Kane R. L., Olsen D. M., Newman J., Manson J. Giving and getting surgery in Utah: an urban-rural comparison. Surgery. 1978 Apr;83(4):375–381. [PubMed] [Google Scholar]
  14. Koran L. M. The reliability of clinical methods, data and judgments (first of two parts). N Engl J Med. 1975 Sep 25;293(13):642–646. doi: 10.1056/NEJM197509252931307. [DOI] [PubMed] [Google Scholar]
  15. LOGAN R. F., EIMERL T. S. CASE LOADS IN HOSPITAL AND GENERAL PRACTICE IN SEVERAL COUNTRIES. Milbank Mem Fund Q. 1965 Apr;43:302–310. [PubMed] [Google Scholar]
  16. Lazaro E. J., Rush B. F., Jr, Landor J., Grimes E. L. Controversies in the management of cancer of the breast: a questionnaire course. J Med Soc N J. 1977 Nov;74(11):943–948. [PubMed] [Google Scholar]
  17. Lewis C. E. Variations in the incidence of surgery. N Engl J Med. 1969 Oct 16;281(16):880–884. doi: 10.1056/NEJM196910162811606. [DOI] [PubMed] [Google Scholar]
  18. LoGerfo J. P. Variation in surgical rates: fact vs. fantasy. N Engl J Med. 1977 Aug 18;297(7):387–389. doi: 10.1056/NEJM197708182970711. [DOI] [PubMed] [Google Scholar]
  19. McCarthy E. G., Finkel M. L. Second opinion elective surgery programs: outcome status over time. Med Care. 1978 Dec;16(12):984–994. doi: 10.1097/00005650-197812000-00002. [DOI] [PubMed] [Google Scholar]
  20. McCarthy E. G., Widmer G. W. Effects of screening by consultants on recommended elective surgical procedures. N Engl J Med. 1974 Dec 19;291(25):1331–1335. doi: 10.1056/NEJM197412192912506. [DOI] [PubMed] [Google Scholar]
  21. Moore F. D. What puts the surge in surgery? N Engl J Med. 1970 Jan 15;282(3):162–164. doi: 10.1056/NEJM197001152820311. [DOI] [PubMed] [Google Scholar]
  22. Munster A. M., Weiner J., Gibson G. Prophylactic antibiotics in surgery. Practices within surgical services of the Veterans Administration. JAMA. 1979 Feb 16;241(7):717–718. doi: 10.1001/jama.241.7.717. [DOI] [PubMed] [Google Scholar]
  23. Norden C., Philipps E., Levy P., Kass E. Variation in interpretation of intravenous pyelograms. Am J Epidemiol. 1970 Feb;91(2):155–160. doi: 10.1093/oxfordjournals.aje.a121123. [DOI] [PubMed] [Google Scholar]
  24. Observer variation in recording clinical data from women presenting with breast lesions. Report from the Yorkshire Breast Cancer Group. Br Med J. 1977 Nov 5;2(6096):1196–1199. doi: 10.1136/bmj.2.6096.1196. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Pearson R. J., Smedby B., Berfenstam R., Logan R. F., Burgess A. M., Jr, Peterson O. L. Hospital caseloads in Liverpool, New England, and Uppsala. An international comparison. Lancet. 1968 Sep 7;2(7567):559–566. doi: 10.1016/s0140-6736(68)92423-9. [DOI] [PubMed] [Google Scholar]
  26. Perkoff G. T., Ballinger W. F., Turner J. K., Kahn L. Lack of effect of an experimental prepaid group practice on utilization of surgical care. Surgery. 1975 May;77(5):619–623. [PubMed] [Google Scholar]
  27. Richardson F. M. Peer review of medical care. Med Care. 1972 Jan-Feb;10(1):29–39. doi: 10.1097/00005650-197201000-00004. [DOI] [PubMed] [Google Scholar]
  28. Roos N. P., Roos L. L., Jr, Henteleff P. D. Elective surgical rates--do high rates mean lower standards? Tonsillectomy and adenoidectomy in Manitoba. N Engl J Med. 1977 Aug 18;297(7):360–365. doi: 10.1056/NEJM197708182970705. [DOI] [PubMed] [Google Scholar]
  29. Rutkow I. M., Zuidema G. D. "Unnecessary surgery": an update. Surgery. 1978 Nov;84(5):671–678. [PubMed] [Google Scholar]
  30. Scott H. D., Mackie A. Decisions to hospitalize and operate: a socioeconomic perspective in an urban state. Surgery. 1975 Feb;77(2):311–317. [PubMed] [Google Scholar]
  31. VERDA D. J., PLATT W. R. The effectiveness of the tissue committee at the Missouri Baptist Hospital. Bull Am Coll Surg. 1958 Nov-Dec;43(6):449–passim. [PubMed] [Google Scholar]
  32. WEINERT H. V., BRILL R. Effectiveness of hospital tissue committee in raising surgical standards. J Am Med Assoc. 1952 Nov 8;150(10):992–996. doi: 10.1001/jama.1952.03680100034011. [DOI] [PubMed] [Google Scholar]
  33. Wennberg J. E., Gittelsohn A. Health care delivery in Maine I: patterns of use of common surgical procedures. J Maine Med Assoc. 1975 May;66(5):123-30, 149. [PubMed] [Google Scholar]
  34. Wennberg J., Gittelsohn Small area variations in health care delivery. Science. 1973 Dec 14;182(4117):1102–1108. doi: 10.1126/science.182.4117.1102. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES