To operate or not to operate? A multi-method analysis of decision-making in emergency surgery.

BACKGROUND: The ability to decide when to operate and when not to operate is a key surgical skill. The aim of this study was to investigate factors affecting that decision.

METHODS: In phase 1, semistructured interviews were used to investigate how expert surgeons decide when to operate. In phase 2, clinical case vignettes were constructed, and 22 general surgeons at various stages of their training indicated whether they would operate and their confidence in patient outcomes.

RESULTS: Interviews answers centered on the theme of "patient outcome," which was defined similarly by all surgeons. In phase 2, surgeons chose to operate when they perceived the outcome with an operation to be better than the outcome without. Surgeons with <5 years of experience were less certain about what outcomes might be. These surgeons opted to perform significantly more operations (40 +/- 4%) than surgeons with > or =5 years of experience (18 +/- 2%).

CONCLUSIONS: A subjective, balanced assessment of the likelihood of patient outcome is crucial in deciding whether to operate. Novices face higher degrees of uncertainty, explaining differences in decisions taken.