Inner Deliberations of Surgeons Treating Critically-Ill Emergency General Surgery Patients: A Qualitative Analysis

STRUCTURED ABSTRACT

Background:

30% of elderly patients who require emergency general surgery (EGS) die in the year following the operation. Preoperative discussions can determine whether patients receive preference-sensitive care. Theoretically, surgeons frame their conversations after systematically assessing the risks and benefits of management options based on the clinical characteristics of each case. However, little is known about how surgeons actually deliberate about those options.

Objective:

To identify variables that influence surgeons’ assessment of management options for critically-ill EGS patients.

Methods:

We conducted semi-structured interviews with 40 general surgeons in western Pennsylvania who worked in a variety of hospital settings. Interviews explored perioperative decision-making by asking surgeons to think aloud about selected memorable cases and a standardized case vignette of a frail patient with acute mesenteric ischemia. We used constant comparative methods to analyze interview transcripts and inductively developed a framework for the decision-making process.

Results:

Surgeons averaged 13 years (SD 10.4) of experience; 40% specialized in trauma/acute care surgery. Important themes regarding the main topic of “perioperative decision-making” included many considerations beyond the clinical characteristics of cases. Surgeons described the importance of variables ranging from the availability of institutional resources to professional norms. Surgeons often remarked on their desire to achieve individual flow, team efficiency, and concordant expectations of treatment and prognosis with patients.

Conclusions:

This is the first study to explore how surgeons decide among management options for critically-ill EGS patients. Surgeons’ decision-making reflected a broad array of clinical, personal, and institutional variables. Effective interventions to ensure preference-sensitive care for EGS patients must address all of these variables.

INTRODUCTION

Emergency general surgery (EGS) consumes significant health care resources, resulting in 3.6 million hospital admissions and $28 billion in costs in the U.S. annually.^1,2 Patients undergoing EGS procedures experience high morbidity and mortality.^3,4 Poor outcomes are more pronounced in the elderly, who comprise an increasingly large proportion of the EGS population. As many as 16% of Medicare patients undergoing emergency laparotomy die prior to hospital discharge; 30% die within six months.⁵ Presumably, these patients may benefit from preoperative discussions to ensure that they receive preference-sensitive care and to avoid potentially nonbeneficial and morbid interventions.^6,7

How a surgeon frames a preoperative discussion conditions a patient’s understanding of their disease and management options.^8,9 For example, when a surgeon encounters a young robust patient with an emergent surgical problem, he or she may briefly discuss the risks and benefits of surgery before recommending an operation. In contrast, when a surgeon encounters an older and/or frail patient, he or she may be more likely to elicit the patient’s goals of care, or even recommend palliation instead of surgery. Even when using best-practice communication strategies, the surgeon may unconsciously frame the discussion so as to nudge the patient towards the decision the surgeon prefers.⁹ Differences in surgeons’ inner deliberations and decisions about the best management option can lead to inter-surgeon variability in preoperative discussions and, ultimately, in management.

Surgeons are thought to make decisions by processing patient data and weighing the risks and benefits of different outcomes.^10–12 However, work from the behavioral science literature suggests that decisions reflect other important variables such as norms, choice architecture, and intrinsic motivations.^13–17 Our lack of understanding of how surgeons assess management options is a critical barrier to improving the care of EGS patients. We sought to explore variables that influence surgeons’ decision-making prior to preoperative discussions in EGS.

METHODS

Overview

We conducted a qualitative study using semi-structured interviews of general surgeons in western Pennsylvania to explore variables that influenced their assessment of management options when caring for EGS patients. The University of Pittsburgh Institutional Review Board approved this study (PRO18020432).

Interview design

We consulted a panel of expert general and acute care surgeons at the University of Pittsburgh (n=5) to generate a list of topics and considerations that might influence surgeon decision-making when evaluating EGS patients and assessment of risks and benefits of management options. We organized these factors into a general framework to develop a guide for structuring the interview. The interview began with open-ended questioning about the surgeon’s general approach and considerations for these patients. Then, we solicited insights on specific cases eliciting satisfaction, dissatisfaction, and/or consternation from the surgeon’s personal experience. To ensure that we elicited decision-making relevant to critically-ill elderly patients and to standardize the interview, we also created a sample case vignette of an elderly woman with acute mesenteric ischemia by abstracting data from a real case. The interview guide and vignette can be seen in Supplement 1. All participants were asked the questions specified in the interview guide, with prompts to probe for additional details or elicit clarification. Then, they were asked to describe their thought process and management approach in the vignette.

Participants and recruitment

We recruited a convenience sample of surgeons with an active EGS component to their regular practice. Due to feasibility constraints, we limited our sampling frame to surgeons working in western Pennsylvania whom we identified through personal contacts and snowball recruitment.¹⁸ We solicited participation via e-mail and attempted to schedule surgeons for in-person interviews as feasible. We conducted interviews over the telephone when necessary. Participants all signed written consent to be interviewed. One author (SSK) conducted all interviews which were audio-recorded and transcribed. We collected participant demographic characteristics including specialty, years of experience, gender, race, and EGS volume. We collected information about participants’ primary hospital including the presence of graduate medical trainees, total number of inpatient beds, and the proportion of total admissions representing Medicare patients from the American Hospital Association Survey 2013. We summarized characteristics using means for continuous data and proportions for categorical data as appropriate.

Qualitative data coding

We used content analysis to inductively analyze interview transcripts, coding them for factors surgeons described as driving their decision-making. A team of four coders (SSK, AB, OAS, DM) met regularly to review interview transcripts. This iterative process also allowed new themes to be added and existing ones to be refined as they appeared in the interviews. We grouped similar themes into categories. We employed constant comparative methods to amend and further expand a framework describing determinants of surgeons’ perioperative decision-making process. Constant comparative methods allow the development of conceptual frameworks when existing models are inadequate.¹⁹ This procedure requires repeated comparison of themes to other themes or properties of thematic categories so that “different categories and their properties tend to become integrated through constant comparisons that force the analyst to make some related theoretical sense of each comparison.”²⁰ This analysis facilitated a description of the relationships between our coded themes, and we ultimately developed a coding framework describing surgeons’ perioperative decision-making (see Figure 1). This framework depicts coded themes and the theoretical influences they might have in the decision-making process. Our coding schema specified a label for each code, a brief definition, inclusion criteria, exclusion criteria, and examples.

Figure 1.

Framework Describing Surgeons’ Perioperative Decision-Making in EGS

Coded themes arranged into an inductive framework demonstrating their influence on surgical decision-making regarding management options in critically-ill emergency general surgery

Reliability and validity of the coding

We ensured the validity of our findings in two ways. First, we used expert input as well as an inductive approach to develop the coding framework. Second, a multi-disciplinary team with expertise in surgery, critical care, palliative care, and qualitative methods reviewed the framework to assess its face and content validity. Once the final framework was developed, we re-coded all the transcripts using two coders, SSK and one other coder (AB, OAS, or DM) to ensure reliability. Differences were reconciled through consensus. We used NVivo qualitative analysis software (QSR International, Melbourne, Australia) for data management.

RESULTS

We contacted 55 surgeons in western Pennsylvania who cared for EGS patients as part of their practice, and 40 (73%) agreed to participate. The interviews occurred both in-person (33) and via telephone (7). Participants averaged 13 years (SD 10.4) of experience; a plurality (40%) specialized in trauma/acute care surgery. Table 1 summarizes other characteristics describing the cohort.

Table 1.

Cohort Summary

Surgeon Characteristics
Variable	Value
Specialty, n (%)
Trauma/Acute Care Surgery	16 (40)
General Surgery	13 (33)
Surgical Oncology	6 (15)
Advanced GI, MIS, Other	5 (13)
Years of experience, mean (SD)	13 (10.4)
Gender, n (%)
Male	34 (85)
Female	6 (15)
Race, n (%)
White	33 (83)
Asian	3 (8)
Black or African American	2 (5)
Hispanic or Latino	2 (5)
Percentage of practice EGS, n (%)
0–25	11 (28)
26–50	21 (53)
51–75	4 (10)
76–100	4 (10)
Maintain Elective Practice, n (%)
Yes	30 (75)
No	10 (25)
Surgeons’ Practice Environment
Variable	Value
Presence of Surgical Residents, n (%)
Yes	28 (70)
No	12 (30)
Number of Total Hospital Beds, n (%)
0–200	5 (13)
201–400	12 (30)
401–600	14 (35)
601–800	2 (5)
801–1,000	0
> 1,000	7 (18)
Annual ED Admissions, median (range)	20,796 (3,104 – 64,223)
Percentage Medicare Admissions, mean (SD)	54 (11.0)

GI = gastrointestinal; MIS = minimally-invasive surgery; EGS = emergency general surgery

We found that surgeons considered a wide range of factors in their perioperative decision-making for EGS patients including clinical variables, individual motivations, and institutional constraints (see Figure 2). Table 2 provides examples of these themes which are discussed in more detail below.

Figure 2.

Relative Contributions of Variable Themes to Surgeon Decision-Making

Relative contributions of themes towards surgeon decision-making grouped by surgeon variables, patient variables, institutional variables, and norms.

Table 2.

Examples of Variables Influencing Surgeon Decision-Making

Themes	Sample Quote	Participants, n (%)
Patient Variables
Problem
Acuity of illness	“Well, the patient’s hemodynamic status (is the patient tachycardic, hypotensive, on vasopressors, requiring active blood transfusions?) will determine how quickly I need to act, how quickly a decision has to be made, not just by me, but the patient’s family or proxy decision-maker.”	39 (98)
Diagnosis	“You need to listen to the history and try to narrow in on what’s in your differential diagnosis.”	40 (100)
Indicated procedure	“And then, probably the third portion of what specifically we need to do, what operation, what approach, which type of intervention, drain, antibiotic choice, comes next after I’ve done this initial triage.”	25 (63)
Characteristics
Age	“She’s already not the best substrate to begin with just because of her age.”	23 (58)
Comorbidities	“Especially here at *** and a growing number at *** are cirrhotics from NASH that don’t even know they’re cirrhotic. So, out here in the community, we tend not to operate on that, especially people who didn’t know they were cirrhotic. Heart failure, got a lot of that. A lot of people with EFs below 20%, all kinds of pacers, AICDs, all kinds of other stuff. And, our new favorite is the new anticoagulants that you can’t reverse (laughs).”	34 (85)
Surgical history	“He had a fairly hostile abdomen.”	8 (20)
Frailty	“I don’t calculate their specific frailty score, I know there’s a few different indices, but I just kind of question their overall functional status, nutritional status…”	21 (53)
Present quality of life	“And, the only reason we proceeded with surgery was that she was super functional.”	14 (35)
Social/caregiver support	“And then, there are social factors. So, does the patient have family support?”	4 (10)
Motivation	“This was a guy who completely neglected his own health, mainly because he was self-employed and had a sick wife…”	4 (10)
Prognostic judgments
Reversibility	“I would take her to the operating room because I think it’s a reversible problem.”	8 (20)
Long-term survival	“Her prognosis is going to be very very poor, probably over 50% mortality given her age and presentation.”	22 (55)
Return to functional status	“If there’s any hope of long-term survival, it would it would include an operation but at the cost of a lengthy ICU stay, a lengthy stay in a nursing home before returning to functional independence. And the return to functional independence may never happen.”	14 (35)
Surgeon Variables
Characteristics
Training	“You know, I trained to be an aggressive surgeon, and I do aggressive things.”	7 (18)
Experience	“When you do this long enough, you know…look, every once in a while, we get lucky. I’ve been doing this long enough, that I know what’s going to happen. I’m pretty confident knowing what’s going to happen.”	14 (35)
Risk Aversion	“I actually think sometimes, “What’s the safe thing to do?” I frame it as what’s the safe option when I frame it to patients.”	11 (28)
Neuroticism	“Yeah, I let my questioning lead to another operation whereas I felt if I had been more decisive, I would have just been done with it.”	22 (55)
Self-awareness	“If something else crazy comes along that you don’t really do too often, you think to yourself, “Hmm, am I really the best person to be doing this?” You know, like a hiatal hernia, right? That’s something that we don’t really see that much. So, you think, “Hmm, is this really best in my hands? Can I handle this?””	11 (28)
Factors that enhance intrinsic motivation
Diagnostic certainty	“It’s kind of refreshing almost, she was so sick that there was no decision to make. I love it when there’s peritonitis, no dilemma.”	26 (65)
Therapeutic simplicity	“Those are very simple but very satisfying cases.”	37 (93)
Smooth resolution	“Did well post-operatively, was out in three or four days. Ostomy matured nicely, never had any ostomy problems. He got his colonoscopy. It was one of those rare times where there was not any particular headache.”	39 (98)
Individual flow	“Actually, I love emergency general surgery because I feel like it’s…I mean it really takes advantage of your surgical skillset, requires a lot of medical knowledge.”	21 (53)
Team efficiency	“Everyone has everyone’s cell phone, so you can get problems solved very quickly. You don’t need to write a note in the chart, wait some time for them to read the note, and then read the answer. You can pick up the phone, say this is the problem, and they take care of it right away.”	31 (78)
Workload	“So, we’re a group of three. So, for each of us to keep coming in to help out with each other’s emergency surgeries sets us up for burnout, so we try not to do that. Obviously, if we have to…”	6 (15)
Pride	“I was pretty pissed off that a patient that I did a big whack on… had the plug prematurely pulled. Especially here where there’s no pancreatic surgery. This is the first pancreas case here in maybe twenty years, or ever.”	13 (33)
Relationship with patient	“So, I think the outcome is important, but the workup, the interpersonal interactions… you have to go from not knowing this patient to establishing full trust for them to hand you a scalpel and say, ‘Here, doc. Cut me within 20 minutes.’ So, I think that’s the most satisfying part of what I do.”	14 (35)
Establishing concordant expectations	“So, for me the most important thing, especially since we have such a huge geriatric population, is trying to get a feeling for what their expectations are for what their quality of life is going to be. And, if I can achieve that, then I’ll operate on anybody even if it’s a long shot. I don’t care. But, when I have somebody tell me that they don’t want to be in a nursing home, they don’t want to lose their independence, but their family is pushing them for an operation, and knowing that, at best, they’re going to be in a nursing home, bed-bound, not independent…that’s not an operation we should be doing.”	33 (83)
Institutional Variables
Critical care	“I called the trauma center because I was like, ‘I don’t have massive transfusion here. Even the other ICU I have here is not going to take care of an 80-something year old lady with an aortic valve on coumadin or anything like this.’”	8 (20)
Consultants	“And, the final thing would be, sort of similar to cardiology care, is what other kind of ancillary services will I need? Will interventional radiology, for example, be able to help me? Do I need a vascular lab to help me with some mesenteric ischemia or something like that? So again, those are some of the technical things. Does ***, which is my main hospital campus, have the facilities to handle this problem?”	17 (43)
Anesthesia	“Sometimes, it also comes to the comfort level of the anesthesiologist. Some anesthesiologists are comfortable putting this patient to sleep here. Some other anesthesiologist may look at that same patient and say, ‘You know what? We’re not comfortable putting that patient here, so please send them out.’”	7 (18)
Colleagues	“I know some places have PAs that are on-call all the time. Sometimes, we have to come in in the middle of the night for a peritonitis case, and it’s me and the scrub nurse and nobody else. There’s a circulator, but she can’t scrub. You can’t get the exposure you need, and it’s very frustrating. We have a policy in my hospital that if we get into that situation and it’s unsafe for the patient, we call a partner in, and we all come in to take care of the patient. I think that’s really important, to have partners you can rely on, that are in town.”	15 (38)
OR/Staffing	“Out here in the community, we have a very limited amount of OR rooms. So, if it comes in later in the evening, you have to try to get it in before a full day starts and you’re bumping people and creating all kinds of havoc in the schedule.”	9 (23)
Patient Mix	We have an underserved community, people who don’t follow up with doctors. So, we have many things going on besides the acute event.”	3 (8)
Access to tertiary care	“We don’t have an OR 24 hours a day, and so, you know, for something truly emergent, you have to think, “Can I get the patient to the OR faster here or faster at ***?”	3 (8)
Norms
Professional	“I think that as a surgeon, your default should be to the operating room. In my residency, the program director would say, “Nobody dies of a negative laparotomy.” Or, in this day and age, a laparoscopy. So, I think, don’t ignore those feelings. You know enough to know what’s wrong, and when something is wrong, that’s the time to help them.”	26 (65)
Institutional	“I think the general theme is that you have to work within your system. And, that ultimately ends up influencing what operations you do, the timing of it, and everything else.”	10 (25)
Societal	“There’s a lot of talk about us taking the lead and telling patients that this is care that borders on futility. Society is a hundred years behind that, I’m telling you. They’re aiming at us, but society’s not ready for that. They need to be blasting that out to the population if that’s the way they want things to go. For right now, it’s a case by case basis, as accurate as you can, a discussion of the risk.”	9 (23)

Patient variables

Problem

All surgeons described their approach to EGS patients as beginning with an assessment of the diagnosis, the likelihood the patient had a surgical problem, and the severity of the illness. Acuity determined how quickly they needed to reach a decision and act. Acuity also dictated triage when dealing with multiple patients simultaneously. Surgeons then considered treatment options such as, “what operation, what approach, which type of intervention, drain, antibiotic choice…” to address the pathology.

Characteristics

After determining the problem, all surgeons considered patients’ other characteristics to help them prognosticate and decide between management options. They usually cited patient age, although this was often “not the main factor.” They frequently commented on comorbidities and how these might affect perioperative care. The patient’s surgical history could inform diagnosis (i.e. postoperative complication) or assessment of the anticipated difficulty of an operation. Surgeons also commented on frailty, functional status, social/caregiver support, and the patient’s motivation to participate in their care and recover. One surgeon commented, “So, all of these things go in my head simultaneously, and eventually [I] will move towards the final decision.”

Prognostic judgments

All surgeons integrated their assessments by determining the likelihood of immediate reversibility, survival, and the patient’s return to pre-existing functional status. Judgments of reversibility were primarily based on whether the pathophysiology arose from “fixable things.” Surgeons highlighted the importance of the patient’s projected survival or “mileage with an operation” when considering surgical options. Finally, surgeons referred to “quality of life” when assessing the likelihood of the patient’s return to their prior functional status. One surgeon posed the judgment as, “Can I make this patient better without severely impacting their quality of life outside the hospital?”

Surgeon variables

Surgeon characteristics

Most surgeons (90%) expressed the belief that their personal characteristics contributed to their perioperative decision-making. Surgeons often acknowledged the impact of their training on their practice patterns. They valued their cumulative experience in providing “wisdom” about when not to operate and cited formative experiences early in their career that continue to influence their decision-making. Surgeons’ degree of risk aversion and conceptions of the “safe” thing to do affected their decisions. Neuroticism (second-guessing) led surgeons to question their decisions which led to “overthinking the next case.” Finally, surgeons’ degree of self-awareness (cognizance of gap in knowledge or technical skill) emerged as an important factor. One surgeon stated “You have to make sure that you have the ability to do it. You have to be honest with yourself.”

Factors that enhance intrinsic motivation

All surgeons cited factors that enhanced their intrinsic motivation as important contributors to perioperative decision-making. Surgeons sought diagnostic certainty (identifying the diagnosis when otherwise unclear), therapeutic simplicity (straightforward management, a problem that is “very easily fixed”), and a smooth resolution of cases (when patients “do okay without any major complications”). Surgeons also expressed the satisfaction they derived from a flow state in which they were able to fully utilize their knowledge and surgical skills in patient care. For example, one surgeon stated, “I find it more satisfying when it’s a challenging case that goes relatively well…when it’s something you haven’t done a lot of, or it’s more nuanced than simple appendicitis.” Finally, pride motivated decisions. One surgeon gave an example where, “It was basically a medical patient they had given up on…they said, ‘She was too sick for surgery.’ I like it when the deck’s stacked against you and you can shepherd these patients through.”

Surgeons derived satisfaction when the whole healthcare team worked together efficiently. Most often they expressed dissatisfaction when this did not occur (“We get a lot of consultations that are…out of the realm of what a surgeon would need to see. Yet, here was an instance where our services were really critically-needed, but no consultation was offered.”) Surgeons desired an appropriate workload (defined differently by different people) to avoid burnout. They relished relationships with patients and opportunities to feel “emotionally-attached and locked in.” Additionally, surgeons were motivated to communicate with patients/surrogates. Though frustrated that “frequently we’re not understood”, they felt satisfied when patients “got it” and truly understood the implications of their illness and treatment options.

Institutional variables

The majority (70%) of surgeons, particularly those at community hospitals, described many “practicalities of today’s medicine”, that affected management. Surgeons spoke about the quality of critical care and availability of an in-house intensivist at night to take care of critically-ill patients. Often, the lack of ICU coverage led them to transfer patients to higher-level centers. Surgeons frequently bemoaned the lack of operating room and staff availability. They blamed low staffing for creating “bottlenecks” for cases. Surgeons frequently considered the extent of help they had from colleagues in discussing difficult cases and assisting in the operating room if needed. Anesthesiologists’ comfort with sick patients played a part in decisions to operate or transfer to a higher level of care. Surgeons also considered the availability of consultants such as gastroenterology, interventional radiology, and specialty surgical services to help with challenging cases. Finally, they considered the hospital patient mix (i.e. socioeconomic status, health literacy, etc. as affecting likelihood of follow-up) and ease of access to tertiary care. As a whole, they expressed “disappointment [that] this lack of resources is affecting the way we manage emergency general surgery patients.”

Norms

Various norms (collective expectations of how one ought to behave) influenced decisions. Most surgeons (83%) commented on their perceived norms of the profession, or in other words, what they felt their responsibility/duty was as a surgeon. Invariably, surgeons emphasized “doing what’s right for the patient.” They felt obligated to try to cure patients (“you don’t win if you don’t play”) but acknowledged their duty to avoid potentially nonbeneficial treatments (“our job is to get people back in the game, and when we bench them, it’s appropriate”). Surgeons also commented on the role that institutional norms (official and unofficial practice patterns) play in decision-making. They felt obligated to “practice within their system.” They also felt pressured to operate due to societal norms and expectations for emergency care. One surgeon stated, “I think, in this country, there’s a lot of unrealistic expectations of what we can do.”

DISCUSSION

To our knowledge, this is the first study to explore surgeons’ deliberations prior to framing management options in EGS. We found that surgeons’ thought processes were influenced by many considerations beyond the clinical characteristics of the patient. Instead, decisions about which management options to offer the patient depended on variables such as the personal characteristics and motivations of surgeons, institutional constraints, and norms.

The paradigm of shared decision-making aims to shift the locus of decisional authority from the physician towards the patient so that both parties engage in the decision process.²¹ Several strategies have been developed to improve physician-patient communication including, notably, “Best Case/Worst Case” scenario planning.²² However, these strategies still necessitate that the surgeon first assess a patient situation, prognosticate, and then frame management options; and, physician recommendations are known to strongly influence patient decisions.⁸ Our work focuses on understanding surgeons’ decision-making one step before they communicate about goals and management options with patients. Most traditional models of this internal process focus almost exclusively on some mathematical risk/benefit assessment using clinical characteristics.^10–12 Our findings suggest that such a narrow construction of the problem fails to capture many of the determinants of real-world decision-making.

Surgeons’ spoke extensively about factors that enhanced their intrinsic motivation. Intrinsic motivation is one’s natural inclination to show interest, explore, seek challenges, and demonstrate mastery in an activity. To be intrinsically-motivated, individuals must satisfy their psychological needs for competency, autonomy, and relatedness.¹⁶ Indeed, surgeons cited several factors relating to the patient, the healthcare team, and themselves that echoed these needs. Specifically, surgeons expressed their desire to fully utilize their training, skills, and knowledge to help critically-ill patients, which we categorized as “individual flow.” Flow has been described colloquially as “being in the zone” and formally as a state of optimal experience in an activity involving mastery, control, and autonomy.²³ Clearly, surgeons may experience flow states while operating, but surgeons’ intrinsic motivation also hinged on positive interactions with patients, colleagues, and other team members.²⁴ In sports and business, individuals driven intrinsically rather than extrinsically (i.e. rewards and punishments) demonstrate enhanced engagement and performance.^23,25,26 In medicine, intrinsically-motivated physicians are more likely to encourage patient medication compliance, adhere to clinical practice guidelines, and contribute to organizational quality improvement efforts.^27–29 Extrinsic motivators such as pay-for-performance measures can improve compliance with measured processes, but they fail to yield true provider behavior change or improvement in patient outcomes.^30,31 Thus, better understanding and leveraging of surgeons’ intrinsic motivation may prove crucial to modifying surgeon behavior and providing preference-sensitive emergency surgical care.

We found that surgeons opined extensively on their sense of professional norms and responsibility. Perceived professional norms shape identities, sense of duty, and decision-making. The importance of identity in driving decision-making has been described in many fields. For example in business, social identities drive consumer habits as well as entrepreneurs’ management styles, all of which drive business outcomes.^32,33 Professional identities in medicine start forming early through socialization into the local culture via both good and bad experiences, and they continue to be molded throughout practice.^34,35 Overall, we saw that surgeons were thoughtful, empathic, and committed to their professional responsibility to “do the right thing.” However, professional norms and identity may not always align with institutional or societal norms, and their intersection may lead to varying conceptions of the “right” thing. Surgeons cited the importance of accounting for available resources in decision-making. They acknowledged the pressure to “work within the system” and avoid potentially unnecessary interventions. They also often felt compelled to operate due to societal norms. Previous studies have demonstrated that surgeons feel pressured to “do everything” due to patients’ unrealistic expectations of what medicine/surgery can accomplish.^31,36 Pressure from conflicting institutional and societal norms can lead to behavior incongruent with physicians’ knowledge or values. For example, physicians may knowingly overprescribe antibiotics due to local practice culture and patients’ expectations of receiving antibiotics. Furthermore, physicians may rationalize these incongruent behaviors by finding some way to align those behaviors with their values (i.e. wanting to maintain a relationship with that patient). Ultimately, norms influence decision-making in different ways in different contexts. We must understand how these contextually-dependent variables influence surgeons’ professional identities and inter-surgeon decision-making variability.

Limitations

Our study has some limitations. Our sample only included surgeons practicing in western Pennsylvania. Our findings may not generalize to surgeons in other regions of the country practicing in different environments, although, our sample characteristics mirror those of the national surgeon workforce.³⁷ Additionally, our sample lacked racial and gender diversity. Differences in decision-making by race and gender may exist and warrant further investigation. And finally, we may have missed some important determinants due to the nature of our interview and surgeons’ recall bias. Nonetheless, our findings illustrate the depth of decision-making in EGS and the imperative to further investigate behavioral determinants.

Conclusions

Popular conceptions of surgeons often portray them as technicians who focus on the problem rather than the patient.³⁸ However, surgeons are far more than simple automatons, and our findings highlight the humanity of surgeons when dealing with challenging life-threatening situations. We found that surgical decision-making in EGS is very complex and is influenced by a multitude of patient, personal, institutional, and cultural variables. Current models of decision-making fail to incorporate many of these important real-world elements. Ensuring that all patients receive preference-sensitive care remains a national priority.³⁹ Given the critical roles that surgeons play in patients’ care decisions, a more comprehensive understanding of surgical decision-making could potentially facilitate the development of targeted behavioral interventions at the level of the individual or institution to further this objective.

Supplementary Material

Supplement 1

Supplement 1. Interview Guide and Sample Case