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Judgement: clinical decision‐making as a core surgical competency
ANZ Journal of Surgery, 2019
Judgement: clinical decision-making as a core surgical competency Judgement: clinical decision-making (CDM) is one of nine core surgical competencies of the Royal Australasian College of Surgeons (RACS) that has been defined across five levels of performance (prevocational; novice; intermediate; competent; and proficient). 1 These levels can be applied to trainees, registrars and consultants alike. 1 In the RACS Competence and Performance Guide, 2 (p19) CDM is defined as "making informed and timely decisions regarding assessment, diagnosis, surgical management, follow-up, health maintenance and promotion". The patterns of behaviour that are indicative of CDM as defined above, describe how key decisions are made at each of four phases of surgical patient care: (1) Deciding what to do (e.g. formulating a working diagnosis and management plan) (2) Preparing to do itwhen an operation or procedure is involved (e.g. pre-operative planning) (3) Reviewing progress while doing it (e.g. intra-operative decision-making in response to the operative findings); and (4) Reflecting, reviewing and responding to how it all went (e.g. post-operative care, debriefing and audit). Collaborative work between the RACS, the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Royal Australasian College of Physicians (RACP) in 2012-2013 helped develop 'mindmaps' that represented the steps within each of the four phases of CDM. Differences between novice and expert clinical decision makers were identified. These mind maps have been incorporated into the current RACS CDM course and are published in journal articles. 3-5 This article discusses two aspects which influence the successful development of competence in CDM. They are (i) the influence of confidence and uncertainty on CDM, and (ii) linking the components of complexity that exist around making clinical including operative decisions. We describe how experts cope with uncertainty and complexity and are still able to make timely and effective decisions. In addition, the expert (ideally) should be able to assist medical students, junior doctors and trainees to understand the processes involved. Arguably, experts can only do so if they understand themselves how they have arrived at their decisions. Better understanding of how an expert does this might enable supervisors and trainers to adapt their work-based supervision and teaching, refine their role modelling and to provide better support and feedback to medical students and trainees to improve their competence (and confidence) with CDM.
Transforming the Surgical "Time-Out" Into a Comprehensive "Preparatory Pause
Journal of Cardiac Surgery, 2007
We propose expansion of the standard "time-out" into a comprehensive "preparatory pause" encompassing five well-documented perioperative risk avoidance strategies: beta-adrenergic blockade, DVT prophylaxis, preoperative antibiotics, normothermia, and euglycemia. Although all members of the surgical team acknowledge the clear benefit of these five prophylactic strategies, published national compliance even in the target patient population is a disappointingly consistent 50%. We have developed and field-tested a "preparatory pause" form that we appended to our "surgical time-out." By politely challenging our surgical team as to the inclusion of these five risk avoidance strategies in 167 consecutive patients, we increased our compliance to more than 90% for each preventive measure. We have not attempted to quantify the physical and psychological benefit of complication avoidance due to the enhanced activation of these five prophylactic strategies. Using published surgical complication prevalence data, with and without these accepted risk avoidance measures, we estimate the number of complications per 100 patients avoided. Utilizing the Medicare payment schedule for each complication, we approximate the purely financial benefit of the "preparatory pause" to be 88,640per100patients,oralmost88,640 per 100 patients, or almost 88,640per100patients,oralmost900 per patient. The now standard surgical "time-out" is designed to avoid the gratifyingly uncommon problem of "wrong patient," "wrong procedure," and "wrong site." Many surgeons negotiate an entire career without stumbling over these disastrous problems. We propose expansion of the "time-out" to include five well-documented perioperative risk avoidance strategies that many of us overlook all too often.
Prevent and Undo Mistakes in Surgery
World journal of surgery and surgical research, 2019
Introduction: Reporting "wrongs" or negative results in Medicine is essential and doing so in surgery should be a moral obligation, to prevent others from making the same mistakes that can bring negative results. Prevention is better than cure! Method: A review is made of the aggravations or negative or non-positive effects that we have found in our own surgical practice in the Surgical Service in the County Hospital of Alcoy, Alicante, Spain for 40 years, and that we publish in order to show that there is a place for surgeons to teach others, so that they avoid negative consequences. Results: We have found 23 subjects to make a correction of the original descriptions or at least draw attention that their correction was necessary. Discussion: Reporting positive results is important in all scientific aspects, but they are much so to communicate the negative effects of our actions, and even more so as doctors in Medicine.
The surgeon has two hands, ten fingers and one patient at a time to deal with ; the musician has two hands, ten fingers plus seven notes to cope with. The talented musician can innovate ; the creative surgeon too. Despite the fact that Surgery is not anymore only an Art, it still has something to do with creativity for the simple reason that hands are bound to artistic creativity. However, the latest and the newest is not always the best whether in Art, Music or Surgery. Therefore, balancing Hubris with Nemesis is appropriate in all those fields. During the performance of a violin or a piano concerto, the conductor must downgrade his ego while facing a good soloist. It is the same in the operating theatre. In addition a good surgeon is a team worker, i.e. two hands and ten fingers, several inflated egos but only one team dedicated to the patient’s care. Claudio ABBADO, the Italian Maestro of the Berliner Philarmoniker Orchestra (Fig. 11), likes to use the German expression of Zusammen Musizieren to describe the goal that the conductor and the orchestra have to reach together. It is all the same in the operating theatre. However, the analogy between an orchestra and an operating theatre terminates when too many outsiders interfere with the Zusammen Musizieren, and when lobbies and so-called health care economist and financial wizards invade the sanctuary that the operating room should remain. Therefore, it’s time for surgeons to take back the helm of the Operating Theatre.
The next step in surgical quality improvement: outcome situational awareness
Canadian Journal of Surgery, 2020
The next step in surgical quality improvement: outcome situational awareness H as surgical quality improvement reached a plateau? There was a time when surgery was the "Wild West." Dogma and individual preference ruled the care of surgical patients-and patients suffered. Although other quality-improvement projects existed before its inception with varying degrees of success, the introduction of the National VA Surgical Risk Study in 1991 was a landmark in patient care. The program that eventually became the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) brought national outcomes and standards of care to the forefront of surgical discussion. By closely monitoring outcomes and comparing those outcomes to peer institutions, hospitals enjoyed lower complication rates by identifying areas of concern and addressing institutional issues in patient care. 1 For many years, participation in ACS-NSQIP correlated with improved patient outcomes; however, the same benefit of ACS-NSQIP adoption has not been realized by institutions recently. 2 Have we reached the peak of our surgical ability, or have our methods for quality improvement become stagnant? While we see a plateau in surgical outcomes, many countries have continued to see a massive increase in health care expenditure. While medical underuse remains an issue in some areas of the world, overuse and unnecessary spending is a real issue in others. 3,4 In 2010 alone, the US Institute of Medicine estimated an annual excess cost from health care-related services at 765billon,765 billon, 765billon,210 billion of which was considered "unnecessary services." 5 Studies comparing health care expenditure in equally matched patient populations show that increased spending does not correlate with improved patient outcomes, and "overuse" of medical resources can be detrimental to patients, both clinically and financially. 6
The Mental Strategies of Surgeons: A Primer – Part II
The Heart Surgery Forum, 2021
In this two part essay, we have addressed the mental skills and strategies of surgeons that students interested in a career in Surgery and residents training in this realm should have or acquire during their trajectories on their career paths. In Part I of this treatise, we covered the concepts of foundations, the hardy personality, preparation, and decision making. In Part II, we will address the concepts of vision, awareness and focus, reflection and analysis, leadership, and independence.
Surgeons' intraoperative decision making and risk management
American Journal of Surgery, 2011
BACKGROUND: Surgical research on decision making and risk management usually focuses on perioperative care, despite the magnitude and frequency of intraoperative risks. The aim of this study was to examine surgeons' intraoperative decisions and risk management strategies to explore differences in cognitive processes.