Table 5.

Surgeons consider the impact of surgical decisions on professional relationships

Theme 4. When deciding if they will offer surgery, surgeons consider not only the risks and benefits for the patient at hand, but how this decision will impact professional trust and relationships with their colleagues.
Interpretation	Examples
Surgeons are reluctant to perform controversial resections that may compromise the trust colleagues have in them.	“Part of dealing with that is making good decisions about who we operate on and not thinking that we can get anybody through anything, because that's obviously not true. I would say if people know that about you, then they are much more willing to have the conversation about the benefit of the patient instead of being constantly focused on the surgical risk to the patient.”
	“One of my mentors was […] definitely a proponent of offering people radical surgery because he felt they didn't have other options […] Certainly, I think that that thinking can get you into trouble […] I think other surgeons might feel that I was being reckless or risky […] Some med-onc providers I think would be concerned that I would be ‘killing their patients’.”
	“If you are careful in your assessment and you are clear […] about the elements that were considered in your decision-making as far as whether they could be operated on or not—and you document your conversation with the patient well—I think people begin to trust that you are using evidence […] and patient-specific variables to make those decisions. It's going to be a much more collaborative process and you will be able to participate in a broader spectrum of patients because they'll trust that you'll do the right thing as far as understanding if the patient is too risky or not.”
	“In a situation where you have a surgeon that operates on everyone who walks through their door with little discrimination as to who is appropriate or not, I think the medical and radiation oncologists will begin to filter who they actually let get to your door.”

Interview responses revealed that surgeons reflect on the potential effects on professional relationships when considering a controversial resection. This theme is supported by quotes from participant interviews. Med-onc, Medical oncology.