Surgeons’ Perspective of Decision Making in Recurrent Diverticulitis

Abstract

Objective:

This study employs qualitative methodology to assess surgeons’ perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making.

Background:

The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons’ current attitudes and opinions.

Methods:

We performed semistructured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework.

Results:

Twenty-five surgeons were enrolled over a 9-month period. There was diversity in surgeons’ gender, age, experience, training, specialty (colorectal vs general surgery), and geography. Surgeons described the difficult process to determine who receives an operation. We identified 7 major themes as well as 20 subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction.

Conclusions:

Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision-making warrant development.

INTRODUCTION

Historically, colon resection was recommended after 2 episodes of diverticulitis to prevent catastrophic recurrence without specific consideration for the quality of life or preferences of patients.¹ Over the past decade, studies have revealed the reduction in mortality with a prophylactic colectomy is minimal, and patients as well as professional organizations now advocate that the primary goal when considering resection should focus instead on quality of life.² This important focus inherently requires that the values, preferences, and goals of the patient are explicitly elicited by clinicians, shared between patient and clinicians and are core to care planning for recurrent diverticulitis. Although shared decision making in recurrent diverticulitis is critical, it remains understudied. National guidelines from the American Society of Colon and Rectal Surgeons recommend that “the decision to recommend elective sigmoid colectomy after recovery from uncomplicated acute diverticulitis should be individualized.”³ Unfortunately, there is little research available to inform this decision process or assess compliance with these guidelines.

Appreciating the surgeon perspective when engaging in evaluation for colectomy is the first step in improving the quality of the shared decision-making process in deciding to undergo surgery or observation. A deep understanding of the decision-making process can only be achieved by using qualitative methodology. The aim of this study was to improve the current understanding of the decision-making process by examining the surgeon’s perspective.

METHODS

This was a qualitative study. The design conduct and reporting of this study was carried out in accordance with the consolidated criteria for Reporting Qualitative research (COREQ) Publications Guidelines, an evidence-based qualitative methodology.⁴ The study was reviewed and approved by the Vanderbilt University Institutional Review Board (Protocol 181400). Informed consent was obtained from each participant.

Purposive sampling was used to recruit interviewees. With the use of the principal investigator’s professional network as well as snowball sampling, we identified a sample of colorectal surgeons (CRS) and general surgeons (GS) to invite to participate. We intentionally sought out a mix of academic/private practice, gender, fellowship training, age, region of North America and setting to maximize perspectives. Email invitations were sent by the principal investigator to eligible participants to participate in a telephone interview. The email invitation contained a link to a REDCap (Research Electronic Data Capture) consent document hosted at Vanderbilt University.⁵ Interested participants completed the consent document and then were contacted by the Vanderbilt Qualitative Research Core interviewer (KB) by email to schedule an interview.

For each interview, open-ended scripted questions were asked using an interview guide developed though a structured process involving both general and colorectal surgeons as well as a PhD psychologist (Supplemental Appendix 1, http://links.lww.com/AOSO/A115). The interview guide was pilot tested by 5 surgeons. Follow-up questions were asked for clarity purposes and to facilitate detailed discussion. Repeat interviews were not carried out and field notes were not collected. Interviews were conducted by phone with the participant in their office. There were no other participants other than the interviewer and the surgeon. The interviews were conducted by KB. She is a female who holds a master’s degree in social psychology. She is currently the Coordinator of the Vanderbilt Qualitative Research Core and has over 10 years’ experience in qualitative research. There was no perceived bias or assumptions in her conducting the interviewer. Participant had no prior knowledge of the interviewer. Participants were compensated with a $100 gift card. Sample size was determined by theoretical saturation.⁶ Once the research team appreciated that no additional data was being discovered, interviews were halted.

Interviews were audio recorded and transcribed. Transcripts were not reviewed by participants. A hierarchical coding system was developed and refined using the interview guide and a preliminary review of the transcripts. Major categories were further divided from 1 to 11 subcategories with some subcategories having additional levels of hierarchical divisions. Definitions and rules were written for the use of each category. The coding system is reported in Supplemental Appendix 2 (http://links.lww.com/AOSO/A115).

Qualitative data coding and analysis were managed by the Vanderbilt University Qualitative Research Core and led by a PhD-level psychologist. Experienced qualitative coders first established reliability in using the coding system on 8 transcripts. Coding of each transcript was compared, and discrepancies were resolved. A total of 2 coders then independently coded the remaining transcripts. The transcripts, quotations, and codes were managed using Microsoft Excel 2016 and SPSS version 27.0. Analysis was conducted using an analytic spreadsheet that contained all the codes, the associated quotes and any contextual text (eg, interviewer question) needed to further understand the quote.

We used an iterative inductive/deductive approach to the qualitative data analysis.^7,8 Inductively, we sorted the quotes by coding category and used the sorted quotes to identify higher order themes and relationships between themes. Deductively, we were guided by clinical knowledge and our knowledge of the literature on shared decision making.⁹ Participants did not provide feedback on findings.

RESULT

Participation

Of 32 surgeons approached for enrollment, 25 (12 general surgeons and 13 colorectal surgeons) agreed to participate and were enrolled over a 9-month period (November 2018–August 2019). The other 7 surgeons either did not respond to requests or were unable to schedule interview times. Table 1 displays participant demographics, years of surgical experience, training, practice type, and geographical location. The median duration of interviews was 23 minutes.

TABLE 1.

Demographic and Practice Characteristics of Participants (n = 25)

Variable	n = 25
Age, y, mean (range)	45 (32–61)
Female	10 (40%)
Practice
Academic	13 (52.0%)
Private	8 (32%)
Hybrid	4 (16%)
Specialty
General surgery	12 (48%)
Colorectal	13 (52%)
Region
Northeast	4 (16%)
South-east	7 (28%)
Mid-west	9 (36%)
West	4 (16%)
Canada	1 (4%)
Setting
Urban	7 (29.2%)
Metro/Suburban	9 (37.5%)
Rural	8 (33.3%)
Fellowship trained	17 (68%)
Years in practice, y, mean (range)	13 (3-28)

Conceptual Framework

First, quotes and themes were analyzed to form a conceptual model of the decision-making process. Figure 1 describes a shared decision-making process in which the risk and benefits of surgery are weighed against the risks and benefits of observation. Using this conceptual framework, we developed Table 2, which lists themes and subthemes with corresponding illustrative quotes. Exemplar quotes from each theme and subtheme are interspersed below.

FIGURE 1.

Conceptual model—decision making in recurrent diverticulitis is complex, involving multiple surgeon, and patient factors and evolving over time.

Table 2.

Summary of Themes, Sub themes and Illustrative Quotes

Theme	SubTheme	Statement
Benefits of Treatment	N/A	I really guide my decisions off of what the potential benefits are of the surgery, the benefit of avoiding an emergency colectomy with a potential colostomy, and the benefits of eliminating future diverticular episodes that cause pain versus the potential complication of surgery. (Participant 15, General Surgery, No Fellowship)
Risk of Surgery	Comorbidity	I look at these comorbidities, are they prohibitive or not? Are they modifiable or not?. Yeah, most patients will have diabetes, hypertension, high cholesterol, these things. Yes, it increases their risk for sure. Obesity, this is the population we deal with. (Participant 23, Colo-rectal Surgery, Colorectal Surgery Fellowship)
	Complexity of Surgery	[If] they’ve had 15 different abdominal surgeries, and hernia repairs, and they have a lot of scar tissue in their abdomen that would make it very difficult to safely perform the surgery. (Participant 19, General Surgery, No Fellowship)
	Complications	Although those things happen infrequently, if your patient [has] a bad complication you’ve changed their life forever and you’re going to live with that on your shoulders. (Participant 10, Colo-rectal Surgery, Colorectal Surgery Fellowship)
Risk of Observation	Immunosuppression	I think the big one is patients are immunosuppressed. We put a lot of emphasis on patients who are immunosuppressed, not HIV so much, but transplantation, patients on chronic steroids would have to be on high dose steroids. (Participant 12, Colo-rectal Surgery, Colorectal and Minimally Invasive Surgery Fellowships)
	Age	Then you’d say, well, they’re gonna live a long time. They’re probably going to have a lot more attacks, they’re at risk for complications. (Participant 16, General Surgery, Minimally Invasive Surgery Fellowship)
	Impact on Quality of Life	So the exact words that I tell them is that when your life starts revolving around your diverticulitis, it’s when we need to consider surgery. If you feel like you can live with this, then it really doesn’t affect how you’re doing anything, then there is no reason to do surgery for it. But if you feel like you’re not living the quality of life that you want to, and it’s otherwise dictating what you’re doing, then that’s when you should consider surgery. (Participant 1, Colo-rectal Surgery, Colorectal Surgery Fellowship)
	Ostomy	Yeah, the bag, the bag, the bag. Everybody that walks in here is afraid of the bag.(Participant 23, Colo-rectal Surgery, Colorectal Surgery Fellowship)
	Efficacy of Observation	...unfortunately, there’s no good data to show that any medical intervention with 5-ASA products, probiotics, anything like that is going to help. ... We really don’t know how to prevent recurrent attacks of diverticulitis or, you know, why you can have millions of people with diverticulum; some get diverticulitis and some don’t. (Participant 7, Colo-rectal Surgery, Colorectal Surgery Fellowship)
Surgeon Factors	Biases	Here is the issue; the issue here is that we are paid for a procedure. When you come to a surgeon, the incentives are altered a little bit. I think that often times we don’t really embrace the patient to become a team member to be able to make educated decisions regarding their care. I think that, my personal opinion is that we’re taking out a lot of sigmoids that may not need it. (Participant 10, Colo-rectal Surgery, Colorectal Surgery Fellowship)
	Experience	I think it’s clear to me in my years of practice that less is more. Less is more. (Participant 10, Colo-rectal Surgery, Colorectal Surgery Fellowship)
	Training	I think it’s with most surgeons, it’s how you, in your training, talking to your partner, train somewhere else or something, talking that stuff with him. We get articles ... but 99% of what you do is related to what the people before you did and taught you how to do. (Participant 18, General Surgery, Minimally Invasive Surgery Fellowship)
	Evidence	You could find a lot of literature to support the way you practice either way. There’s a lot of conflicting data. ... That’s why it can’t be this two-minute doctor visit. You’ve got to spend some time with them. They have to understand the whole thing because they’re weighing a lot of different competing agendas. (Participant 24, Colo-rectal Surgery, Colorectal Surgery Fellowship)
Patient Factors	Mental Model	... it’s individual because there are some people who would prefer to be hospitalized twice a year than to incur the risk of an operation. And then there are people who are just the opposite. (Participant 25, General Surgery, Minimally Invasive Surgery Fellowship)
	Motivation	I try to get a sense from the patient of how intrusive these episodes of diverticulitis have been, and then I try to get a sense from the patient about what their motivation for surgery is. Is it that they want to get rid of chronic abdominal pain? Is it the fear of getting the next episode? Is it the fear of coming in with a perforation and needing a bag? (Participant 23, Colo-rectal Surgery, Colorectal Surgery Fellowship)
	Expectation	It seems that most patients come in kind of already knowing what they want to do. Some patients just know that they don’t ever want to do this again and it’s very easy and then other patients usually know if they’re going to be for it or against it. (Participant 21, General Surgery, No Fellowship)
	Psychosocial	I ask them to think about the lifestyle impact that the disease is affecting. I have had many patients who are a bit older and want to take vacations and they’re somewhat fearful of taking a vacation, especially far away because of this problem and they want to opt for a cure rather than intermittent management. There are people who are teachers who are looking to have things done in the summertime. There are people who are farmers who just cannot be off the farm during harvest time, perhaps. There are some people, say pilots, who just feel that they cannot afford to get sick while they are on duty. (Participant 25, General Surgery, Minimally Invasive Surgery Fellowship)
Decision Process	Assessment of Burden	I look at the number of episodes they’ve had and how severe those episodes have been, whether or not they’ve been treated with outpatient antibiotics or required admission, if they’ve ever had a perc drain put in, things like that. (Participant 11, General Surgery, No Fellowship)
	Proper Selection	...if people come in with symptoms that they attribute to their diverticulitis, but we have no radiographic correlate with that, I think that may be more related to folks having functional issues that may or may not be related to the diverticulitis. I think those folks, as we always say with surgery, operate for pain, you get pain. (Participant 6, Colo-rectal Surgery, Colorectal Surgery Fellowship)
	Accurate Expectations	I think a lot of it’s expectations to be honest with you, you know like this is just like taking out a loan or any experience that you’re engaging in, if the expectation are outlined ahead of time, then I think patients fare far better knowing what lies ahead of them then if they’re kind of sold this oh we’re gonna have surgery and you’re gonna be out of the hospital in 2.8 days and you’re just gonna feel great.(Participant 9, General Surgery, No Fellowship)
	Empower patient choice	I think most patients still have a very paternalistic view of healthcare, at least in my practice, so they want you to tell them what to do. I disagree with that approach, so my main job is to make sure they understand why they’re here, and then I try to educate them enough so that they can make a decision about what they want to do. (Participant 24, Colo-rectal Surgery, Colorectal Surgery Fellowship)
Change over time	N/A	I grew up being instructed that patients, after one episode of complicated diverticulitis, should be recommended surgery and that used to be my practice. One episode of perforation, regardless of how bad the perforation was would essentially guide me to instruct the patient that they should undergo elective resection. Even recurrent episodes, even if they were minor, I think we used the number, completely random number of two, three, three episodes in a young, healthy patient of recurrent episodes that would incapacitate them for at least a couple of days, would be an indication to operate on them to avoid the fear of a severe episode down the line. Almost prophylactic indications were big. That’s changed a lot. ... Now, the criteria that I use are much more focused on actual symptoms and impact on quality of life. (Participant 12, Colo-rectal Surgery, Colorectal and Minimally Invasive Surgery Fellowships)

Perceived Risks of Each Approach

Almost unanimously, surgeons stated that the decision hinged on comparing the risk of surgery versus the risk of continuing observation.

I lay out basically risk equations. And I say, “This is your risk, if you don’t have surgery. And this is your risk, if you do have surgery.”… [I] help them come to a conclusion about what they want to do. (Participant 22, GS)

In defining the risk of surgery, several surgeons cited comorbidities as an important factor. These included cardiopulmonary status, frailty, diabetes mellitus, and the need for anticoagulation. Several surgeons pointed out that some comorbidities are modifiable and require attention before a potential operation.

I mean if they’re medically unfit for surgery, that’s a barrier. (Participant 16, GS)

The anticipated complexity of the surgery was another important element. Issues such as previous abdominal surgeries, obesity and the degree of anticipated scarring were all cited as issues to consider.

[If] they’ve had 15 different abdominal surgeries, and hernia repairs, and they have a lot of scar tissue in their abdomen that would make it very difficult to safely perform the surgery. (Participant 19, GS)

Complications from surgery were discussed as a major concern with a surgical approach. Surgeons spoke about the obvious negative outcome that comes from complications as well as a way to reduce potential complications. Anastomotic leak was the major complication discussed, along with hernia, stricture, and recurrence.

Finally, surgeons identified both the financial and opportunity cost of surgery as an issue for patients. This included the direct cost of surgery as well as time away from work and family.

With high deductible plans now days, patients are on the hook for a lot of money for these operations and that is a major consideration … (Participant 1, CRS)

For the risk of continued observation, a few surgeons identified immunosuppressed patients as a separate category when considering observation.

Then the other factor with diverticulitis that comes into play is immunosuppression. Those patients are much less likely to do well with non-operative therapy, and so I’m more likely to offer surgery even though it’s higher risk for them. (Participant 8, CRS)

The patient’s age was another matter when considering observation. This was an area of mixed opinion for surgeons. Some felt that young age was an indication to be more aggressive with surgery because younger patients had longer to continue to develop recurrence and subsequent sequalae.

Then you’d say, well, they’re gonna live a long time. They’re probably going to have a lot more attacks, they’re at risk for complications. (Participant 16, GS)

Others dismissed young age as an indication for surgery, instead highlighting other factors such as number and severity of recurrences.

… how many times they’ve had recurrence and how life limiting it is. (Participant 2, CRS)

Impact of recurrence on quality of life was a theme highlighted throughout the interviews. Fear of another episode was felt to limit patients in both their professional and personal lives.

Then, for me, it gets into scenarios where some patients when they get an attack it is severe, and it really is a problem. In other words, it affects their quality of life. (Participant 10, CRS)

Many surgeons cited the fear of emergent surgery and potential colostomy as a consideration for observation. Although almost all acknowledge that this is an issue for patients, many reported the need to educate patients that the risk of emergent surgery was low.

I don’t use the fear of an ostomy anymore, because almost always the worst attacks are the first attacks. (Participant 13, CRS)

Finally, surgeons expressed frustration at the lack of any meaningful medical therapy to prevent further recurrence of diverticulitis. Although surgeons may recommend high fiber diet, 5-ASA, probiotics, and antispasmodic agents, almost all surgeons recognize the lack of literature on medical management. A number spoke against the use of suppressive antibiotics outside of a bridge to surgery.

Really, the data isn’t great and the medical management of diverticular disease isn’t great, (Participant 15, GS)

Patient and Surgeon Factors That Influence the Decision

Along with assessment of risk, interviewees discussed surgeon and patient factors that influence the decision. The first of these on the patient side is the mental model that patients use to integrate their diverticular disease into the larger sense of their life. Although some patients conceptualize their diverticulitis as a smaller feature in their overall being, for others diverticulitis is a large focus of how they live their life.

So, it’s very personal or I should say it’s individual because there are some people who would prefer to be hospitalized twice a year than to incur the risk of an operation. And then there are people who are just the opposite. (Participant 25, GS)

Patients’ motivation was described as another significant factor. Some patients seem to be very focused on undergoing surgery, whereas others are motivated to avoid surgery at all costs.

Some patients come in with their mind already made up like I want surgery. I usually try to make the process over more than one visit. (Participant 23, CRS)

Similarly, patients had varying expectations for the decision-making process and surgery. Surgeons described that a substantial amount of their conversation centers around understanding and adjusting a patient’s expectation for both the natural history of diverticular disease and surgery.

It’s really aligning their motivations with what I think are indications for surgery. Their fears with the real risks of surgery. (Participant 23, CRS)

Finally, the psychosocial context was cited as a strong element in a patient’s decision to undergo surgery. This included the interpersonal context of their lives—a patient’s social network and relationships. Surgeons described the psychologic stress that potential recurrence of diverticulitis places on patients. This was seen to affect a patient’s work and leisure activity as well as interactions with family and friends.

The first step is really to understand how the diverticulitis has impacted their life and really getting a handle on how much of an impact it’s had on not just health [but] time away from work, and family, and activities and time spent in the hospital and how much it’s impacted their travels. (Participant 12, CRS)

There were several factors that influenced a surgeon’s role in the decision-making process. Surgeons appreciated their own biases played a great role in their discussions with patients. Specific biases identified included previous serious complications, the peer environment that they practiced in and their comfort level in managing complex colorectal cases. In addition, the fact that almost all surgeons operate in a fee-for-service environment was cited as a potential bias toward offering surgery.

I have biases. I think everybody has conscious and subconscious biases when we offer surgery to patients. (Participant 1, CRS)

Surgeon experience was identified as a major influencer. This theme includes both experience with previous patients and with peer surgeons who informed their decision making.

You just have to do it [the decision to operate] based on what you’ve learned and experienced and what other people are doing in their own practice. (Participant 21, GS)

Surgeons also cited their training as a strong factor in their decision-making process. Finally, there was wide diversity in the evidence used in the decision-making process. Multiple modalities were cited as sources, from journals to meetings to national guidelines to social media to peer discussions. Some surgeons use risk calculators in their discussion with patients. Other surgeons discussed the difference between the North American literature and European literature. Numerous surgeons discussed the difference in practice between general surgeons and colorectal trained surgeons. This juxtaposition was mainly cited in differing adherence to evidence and national guidelines. A common thread throughout the discussion of evidence was the lack of high-quality evidence to guide the decision-making process.

Literature. I think mainly literature, practice guidelines, meetings, colleagues. (Participant 10, CRS)

I’m not much of a journal person. I actually think journals are my least favorite source of information. I think the journals are generally self- serving garbage. (Participant 22, GS)

In the background of these elements was the concept of “evolution over time.” Across almost all interviews, surgeons describe the dynamic nature of the decision-making process. They often describe how they used to make decisions to offer an operation juxtaposed with how they currently make the decision. A few factors have influenced this change, from the literature to national guidelines to peer discussions.

I tell them this used to be real easy, used to be clear cut rules, and now it’s not, and now it’s almost entirely based on how they feel this is impacting their quality of life. (Participant 13, CRS)

Decision-Making Process

Finally, surgeons discussed at length the decision-making process they go through with patients. Almost all interviewees reported that this was usually a difficult process both for the surgeon and the patients. This discussion typically began with an assessment of the burden of the diverticular disease. Elements included the overall number and frequency of attacks with increasing frequency generally cited as a factor to recommend surgery. Interestingly, several surgeons still adhered to more historical guidelines of “three strikes and you are out.”

I try to go by the old teaching of if you have at least three attacks of diverticulitis, no matter the age, then you’re a good candidate for elective sigmoid colectomy. (Participant 21, GS)

Severity of attacks also was discussed. Differences were identified between inpatient and outpatient management, complicated (including previous abscess and drainage) and uncomplicated diverticulitis and the duration of each attack. Surgeons identified a subsection of patients with a stricture, fistula or smoldering symptoms as more likely to benefit from earlier surgery.

I look at the number of episodes they’ve had and how severe those episodes have been, whether or not they’ve been treated with outpatient antibiotics or required admission, if they’ve ever had a perc drain put in. (Participant 11, GS)

Surgeons stressed the need to properly select patients for consideration of colectomy. A recurring theme was the heterogeneity of symptoms that can result from an attack of diverticulitis. A result of this was the need to ensure that the symptoms were consistent with diverticulitis and that colectomy was reasonable to address the symptoms.

Meaning if people come in with symptoms that they attribute to their diverticulitis, but we have no radiographic correlate with that, I think that may be more related to folks having functional issues that may or may not be related to the diverticulitis. (Participant 6, CRS

Surgeons then worked to personalize the decision-making process for each individual patient. They usually considered the severity of the disease, the patient’s comorbidities, the complexity of surgery and the expected success of the surgery based on the disease frequency and severity. This mostly manifested as a classic discussion of the perceived risk and benefits of surgery.

It’s all risk benefits thinking about how is this surgery going to benefit this person. They don’t have a cancer. This is a risk reducing operation (Participant 10, CRS)

Interviewees stressed that setting accurate expectations for either surgery or observation was essential to a successful outcome. This was generally described as a 2-step process. The first step was to assess the patient’s goals and determine what they considered a successful outcome. Second, there was a significant amount of education to be provided both on surgical options as well as the untreated natural history of the disease.

I just do my best to kind of give them an expectation for what would happen if they decide the surgery and an expectation for what I anticipate would happen with different scenarios. (Participant 22, GS)

Finally, surgeons spoke at length about the necessity of empowering patient choice. This is a move away from the paternalistic/maternalistic model of the surgeon telling the patient what is best for them. Rather surgeons sought to inform and then engage patients in the decision-making process.

I think an educated patient makes a decision that is best for them. (Participant 16, GS)

DISCUSSION

To better understand the decision to undergo colectomy for recurrent diverticulitis from a surgeon perspective, we conducted a qualitative study by performing semistructured interviews with a wide range of surgeons who perform colectomy for recurrent diverticulitis. Through a diverse range of experiences and answers, we identified several themes involved in the decision-making process, including patient and surgeon factors, risk and benefits of both surgery, and observation and key elements in how to make a shared decision. Results from this analysis will inform the way we study this disease and identify important elements of shared decision making for both patients and providers.

Although literature on formal shared decision making for surgery in general is relatively limited^9–14, it is nonexistent in the case of elective colectomy for diverticular disease. Most work has focused on a small number of clinical areas—plastic surgery, breast cancer, and osteoarthritis. Collectively, these studies have observed that shared decision making reduces decision conflict, increases knowledge, and improves decision quality for patients making choices about elective surgery. Qualitative studies on shared decision making in these areas have discovered important elements such as a knowledge gap among patients undergoing breast conservation therapy for breast cancer,¹¹ alteration of the doctor-patient relationship due to societal change and the judicialization of medicine in spine surgery,¹⁵ and development of a conceptual framework for women undergoing cosmetic and reconstructive breast surgery.¹⁶ Although colectomy for diverticular disease shares some elements with these findings, most notable the focus in optimization of quality of life, there are important differences. As opposed to plastic and breast surgery, cosmesis is not a primary focus. Spine surgery carries a very different complication profile. This current study provides crucial information to inform the shared decision-making process from the surgeon’s perspective.

The qualitative study design allowed for the exploration of a range of complex factors associated with the decision to pursue colectomy. By beginning with open-ended questions and without preconceived notions, this methodology allowed exploration on the breadth of the surgeon’s perspective on shared decision making for recurrent diverticulitis. Notable in these findings are first the complexity and heterogeneity of the decision-making process. Surgeons report balancing a range of patient and surgeon factors along with competing risks of colectomy and observation as well as a nuanced decision-making process. The fact that surgeons have such a varied approach to deciding whether to offer colectomy may explain observed differences in national rates of diverticular resection.¹⁷ Surgeons also lamented the paucity of data to guide decision making. There are several surprises in the findings. Some surgeons still adhere to antiquated guidelines that 3 episodes requires a colectomy.¹⁸ Surgeons cited both the low quality of current data as well as the ease of counting episodes as the reason for this. At the same time, most surgeons noted both that guidelines and their own practice has changed or evolved over time. This was noted to be in response both to published data as well as their own personal experience. Many surgeons highlight the importance of establishing a clear diagnosis of diverticulitis rather than disease patterns with similar symptoms. It was observed surgeons believe that the severity of impact on a patient’s quality of life was perhaps more dependent on psychosocial factors than the degree of physiological dysfunction. This is notable because surgeons are traditionally well trained to handle the biomedical component of disease but may be less equipped to manage the psychological social and cultural dimensions of illness.¹⁹ Finally, there is the near universal acceptance that the primary driver of colectomy is to improve the patients’ quality of life. For both surgeons treating patients with recurrent diverticulitis and researchers studying this population, these are crucial issues to consider.

There are important limitations to consider when interpreting the conclusions. First, though we made a substantial effort to include a heterogenous population of surgeons, we may not have heard all opinions that exist on these issues. As an example, we did not collect the race and ehtnicity of surgeons. However, the variety of surgeon practices demonstrated in Table 1 as well as the fact the thematic saturation was reached provide evidence that the majority of opinions on these issues were heard. Second, this study does not include the patient perspective. We plan to address this with a follow-up study utilizing patient focus groups to gain better understanding into the patient’s decision-making process. Finally, as a qualitative study, it is subject to the inherent biases of the staff conducting the study. To minimize this bias, all authors involved with collection and analysis of data have extensive training in qualitative methods.

This study has several far-reaching implications. First, it provides a conceptual framework from a surgeon’s perspective for shared decision making in recurrent diverticulitis. This framework can be used for hypothesis generation to inform future research efforts. Especially important will be the use of patient reported outcomes in assessing the efficacy of colectomy.²⁰ Although a number of studies have begun this work,^21–24 there remains much to be done. Second, it demonstrates the complexity of this decision-making process for colectomy in this disease. The observation that nontraditional patient factors, such as a patient’s mental model of disease and psychosocial factors, inform the decision-making process suggest that some surgeons may be ill equipped to effectively communicate with patients. This also can lend itself to implicit bias.²⁵ Surgeons may benefit from better support in terms of both skill and resources to effectively inform the decision-making process. This can include training in patient-centered care and utilizing decision aids in the shared decision-making process.^26,27

Logical next steps from this study include investigation into the patient perspective as mentioned earlier. Also, it is important to study further improving the shared decision-making process in recurrent diverticulitis. Although it is widely acknowledged that treatment plans need to be individualized, there is little to no guidance on how this is to take place. There is also the obvious need for more high-quality data in this field. As further information is accumulated, we can move toward more standardized guidelines and reduce national variation.

ACKNOWLEDGMENTS

The authors wish to thank all the individuals who gave their time for interviews and focus groups. We are excited to amplify their voices in this manuscript. They also wish to thank Anne Zimmerman Hawkins for her editing and Russ Beebe for his help with the graphic design.