Pediatric neurosurgeons’ philosophical approaches to making intraoperative decisions when encountering an uncertainty or a complication while operating on children

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  • 1 School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario;
  • | 2 Department of Gender, Sexuality, and Women’s Studies, Simon Fraser University, Burnaby, British Columbia, Canada; and
  • | 3 Department of Pediatric Neurosurgery, Dana Children’s Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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OBJECTIVE

The objective of this study was to explore approaches to intraoperative decision-making in pediatric neurosurgeons when they encounter unexpected events, uncertainties, or complications while operating on children.

METHODS

Twenty-six pediatric neurosurgeons from 12 countries around the world were interviewed using a semistructured interview guide. The grounded theory method of data collection and analysis was used. Analysis involved line-by-line coding and was inductive, with codes and categories emerging from participants’ narratives.

RESULTS

When asked to discuss the strategies they used to make intraoperative decisions, neurosurgeons reported three distinct approaches that formed a philosophy of practice. This included the theme of professional practice—with the subthemes of preparing for uncertainty, doing no harm, being creative and adaptive, being systematic, and working on teams. The second theme pertained to patient and caregiver practices—with the subthemes of shared decision-making and seeing the whole patient. The third theme involved surgeon practice—with the subthemes of cultivating self-awareness and learning from experience.

CONCLUSIONS

Pediatric neurosurgeons have a structured, diverse, and well-thought-out analytical philosophy and practice regarding intraoperative decision-making that encompasses a range of approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment techniques.

ABBREVIATIONS

OR = operating room; PI = principal investigator.

OBJECTIVE

The objective of this study was to explore approaches to intraoperative decision-making in pediatric neurosurgeons when they encounter unexpected events, uncertainties, or complications while operating on children.

METHODS

Twenty-six pediatric neurosurgeons from 12 countries around the world were interviewed using a semistructured interview guide. The grounded theory method of data collection and analysis was used. Analysis involved line-by-line coding and was inductive, with codes and categories emerging from participants’ narratives.

RESULTS

When asked to discuss the strategies they used to make intraoperative decisions, neurosurgeons reported three distinct approaches that formed a philosophy of practice. This included the theme of professional practice—with the subthemes of preparing for uncertainty, doing no harm, being creative and adaptive, being systematic, and working on teams. The second theme pertained to patient and caregiver practices—with the subthemes of shared decision-making and seeing the whole patient. The third theme involved surgeon practice—with the subthemes of cultivating self-awareness and learning from experience.

CONCLUSIONS

Pediatric neurosurgeons have a structured, diverse, and well-thought-out analytical philosophy and practice regarding intraoperative decision-making that encompasses a range of approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment techniques.

ABBREVIATIONS

OR = operating room; PI = principal investigator.

In Brief

Pediatric neurosurgeons have a structured and well-thought-out philosophy and practice regarding intraoperative decision-making that encompasses a range of approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment techniques.

Decision-making is a critical part of a surgeon’s practice.1–4 Decisions include whether to perform surgery, what type of surgery to perform, whether to change course during a surgery that has begun, and how to respond to unexpected events due to complications or adverse events.5 One aphorism that expresses this idea well states: “A good surgeon knows how to operate. A better surgeon knows when to operate. The best surgeon knows when not to operate.”5 Despite the importance of decision-making in surgical practice, little is known about how surgeons think about making decisions during their surgeries. The vast majority of research to date has focused on decision-making during the preoperative stage.6,7

One study of 10 surgeons described two main strategies in making intraoperative decisions (e.g., type of intervention, choice of instrument, etc.). These included relying on clinical experience and/or intuition to guide decisions, or making decisions based on rules that could be clearly articulated.5 For decisions that involved a higher level of uncertainty, surgeons tended to rely on clinical experience and intuitive hunches.2,4 Routine procedures, on the other hand, tended to result in more rule-based approaches to decision-making.5 Other studies suggested that decision-making during surgery involves a process of two stages: assessing the situation and selecting a decision strategy. These decision strategies tended to be either intuitive or analytical.2,4

Whereas the research on intraoperative decision-making is sparse, the research on pediatric (and adult) neurosurgery is almost nonexistent. Only one published commentary exists on this topic that focuses on making an intraoperative decision to abort surgery midway.8 In this paper, Roth and Constantini suggest that decision-making during surgery is affected by multiple factors including medical concerns (i.e., individual differences in anatomy) and technical issues (i.e., equipment failure), but also by surgeon-related “judgmental distractions.” These are factors that may negatively affect intraoperative decision-making and include the following: the surgeon’s perception that aborting surgery is a personal and professional failure; having excessive or unwarranted self-confidence; and fearing colleagues’ and patients’ potentially negative judgment.8

The research available to date is almost exclusively about surgeons who operate on adults in nonneurosurgery contexts, and tends to focus on factors that might influence a surgeon while they are operating. Although volumes of research exist on the surgical/medical practice of pediatric neurosurgery, little has been written about pediatric neurosurgeons themselves. Moreover, whereas some research exists on decision-making in surgeons in general, nothing is known about how pediatric neurosurgeons make these calls during their own practice and how they approach these problems philosophically. To our knowledge, no studies have looked at the thought processes or philosophies of pediatric (or adult) neurosurgeons about making intraoperative decisions. As such, the purpose of this study was to explore approaches to intraoperative decision-making in pediatric neurosurgeons when they encounter unexpected events, uncertainties, or complications while operating on children.

Methods

Study Design and Participants

The grounded theory method of data collection and analysis was used.9 Grounded theory is an empirical, rigorous, and systematic qualitative method that is often used for topics that have not been explored before, and thus require an in-depth approach to data collection and analysis.9,10 Given that qualitative research aims to investigate the underlying aspects of behavior and is concerned with the richness rather than the representativeness of data, it requires smaller, focused samples instead of large, random samples.9 Twenty-six pediatric neurosurgeons were recruited from 12 countries around the globe and interviewed about their intraoperative decision-making strategies.

Procedure

Approvals were obtained from the appropriate research ethics board prior to launching the study. Potential participants were emailed information about the study by the neurosurgeon coinvestigators and asked to respond if they wished to be contacted about the research. A secondary recruitment strategy involved snowball sampling by asking participants taking part in the study to identify colleagues who would be willing to hear about the research. In all cases, interested pediatric neurosurgeons contacted the principal investigator (PI) (L.G.) directly; the PI is not a pediatric surgeon and did not know the participants prior to starting the study. Inclusion criteria included treating and operating primarily on children and being past the residency/fellowship stage. All potential participants had to be at the level where they were responsible for making their own intraoperative decisions.

Twenty-six pediatric neurosurgeons responded to these recruitment methods and none declined to be interviewed. Participants signed a consent form and agreed to the interview being audiorecorded. A semistructured interview guide was used. In line with the qualitative research approaches, all participants were asked a standard set of questions. However, the interview guide was flexible in allowing for new topics to emerge and for unique probes to be asked when surgeons brought up new topics. The study PI conducted all the interviews in English. For some surgeons English was a second language; however, the vast majority of participants were proficient enough in the language to participate comfortably in the interview. One neurosurgeon was interviewed with a translator. Questions focused on approaches to making intraoperative decisions when encountering uncertainty or a complication, as well as on the decision to abort a surgery without completing presurgical goals (see Appendix A). Interviews were conducted using videoconferencing technology and lasted 45–75 minutes. Interviews were recorded and transcribed, with all identifying information removed from the transcripts prior to beginning the data analysis.

Data Analysis

Data analysis was conducted by the research assistant (S.S.), who met weekly with the study PI to discuss the coding process. Data collection and analysis took place concurrently. Following the methods of Charmaz,9 themes emerged from the data and not from preconceived hypotheses. The coder examined the data line by line and coded the segments with names/labels reflecting the actions, themes, feelings, and thoughts of the participants. Initial codes remained close to the data and reflected words and statements used directly by study participants. This type of initial coding allowed for a critical and analytical examination of the data, generated new ideas, and guided further data collection. By comparing data to data as well as data to codes, we were able to determine which among the initial codes were the most salient and made sense in category development. Throughout the process of data collection and analysis, the study team met frequently to discuss emerging findings and to ensure consistency in the emerging coding scheme. Data collection stopped when the team determined that we had reached saturation, meaning that no new themes emerged from the data analysis. Nvivo 12 software, a computer-assisted qualitative data management program, was used to store and organize the data.

Results

Twenty-six pediatric neurosurgeons who worked primarily in academic hospitals participated in the study (Table 1). When asked to discuss the strategies they used to make intraoperative decisions, neurosurgeons reported three distinct approaches that formed a philosophy of practice. This included the theme of professional practice—with the subthemes of preparing for uncertainty, doing no harm, being creative and adaptive, being systematic, and working on teams. The second theme pertained to patient and caregiver practices—with the subthemes of shared decision-making and seeing the whole patient. Finally, the last theme involved surgeon practice, which included the subthemes of cultivating self-awareness and learning from experience. Each of these findings is described in more detail below and is presented in Table 2 with additional supporting quotations.

TABLE 1.

Demographic data for study participants (N = 26)

CharacteristicValue
Sex, % (no.)
 Male81 (21)
 Female19 (5)
Mean age in yrs55
 Range37–74
Countries represented*12
Yrs in practice, % (no.)
 ≤43.8 (1)
 5–1011.5 (3)
 11–2034.6 (9)
 21–2923.1 (6)
 ≥3026.9 (7)
No. of patients seen per wk, % (no.)
 20–3038.5 (10)
 31–4019.2 (5)
 41–5015.4 (4)
 51–607.7 (2)
 ≥6119.2 (5)
No. of surgeries per wk, % (no.)
 1–323.1 (6)
 4–653.8 (14)
 7–1011.5 (3)
 11–157.7 (2)
 ≥163.8 (1)
Total no. of hrs working per wk, % (no.)
 40–5020 (5)
 51–608 (2)
 61–7028 (7)
 71–8036 (9)
 ≥808 (2)

Belarus, Brazil, Canada, Costa Rica, Egypt, Germany, India, Israel, Japan, South Africa, Switzerland, and US.

Information was not provided by 1 participant.

TABLE 2.

Pediatric neurosurgeons’ philosophical approaches to making intraoperative decisions when encountering an uncertainty or a complication

ThemeSubthemeSelected Supporting Quotes
Professional practicePreparing for uncertainty

“A lot of the judgment in the operating room occurs as a result of thinking things through before you get there, like a battle plan, you want to win the war. You need to have strategy. You need to think of any operation as going to war. You try to think of the contingencies in advance, as many as you can, so that if you come up against something you know what to do.” (participant 1)

--

“The decision-making starts much, much before [the surgery]. It’s not the night before. It’s probably weeks before, days before, etc. And during those days we decide on a particular plan, a particular plan A and plan B, C, D, E, and keeps on going. And I mean, A is when we have our ideal scenario when all my vision falls into place. B, C, D, etc., depends on what is going to happen with different combinations of probabilities.” (participant 7)

--

“I’m really a big proponent of the six P’s principle: proper planning prevents poor performance. [laughs] So I always have like stuff on the set to deal with a case that happens, so that if it happens, you just grab this stuff and go.… So most of the time you are somewhat prepared. You are able to prep for it. And that’s when ‘autopilot’ [comes in]—you don’t have to stop and really think about what you’re going to do. You’re just doing it because you’ve already planned what you would do in the event of one of these complications and it’s ready in case it happens.” (participant 8)

--

“For the sake of effecting a cure, we have to take calculated risks. But to me, to some extent, it’s a little bit like mountaineering. And I remember watching a documentary about solo mountaineering and free—free solo climbing without ropes. And listening to a documentary, one of the guys who was at the top of his field in it—and people had described him as being brave and without fear—and he says, quite to the contrary, he is always fearful. And that’s why he goes through the process of—he puts in a huge amount of time planning all these climbs. And doing it with ropes and knowing exactly where all the pitfalls are before he does it without ropes. So even though I’ll take on the complex things, I’m still incredibly, incredibly fearful with every operation that I do. I think it’s managed fear.” (participant 13)

Do no harm

“My feeling is always: safety first. So if there’s any doubt about anything, we will stop and back out. So, you know, safety is number one and I can always explain safety. I joke with the parents, we can always take out more brain tissue, we can’t put it back.… The worst thing a surgeon can do is persist in a situation that doesn’t quote unquote feel right.” (participant 3)

--

“Your goal is always not to hurt the child. Whenever we go into surgery, that’s always the primary undertaking, that our goal is not to harm the patient.… So even though I’ll take on the complex [cases], I’m still incredibly, incredibly fearful with every operation that I do.” (participant 13)

--

“First do no harm. The active omission—you know if you leave some tumor in, you have to go back. That’s much better than taking out an important stretch in the brain. So in those particular cases, it’s better to leave some in, than take too much out.” (participant 15)

--

“And we may have an opportunity where we have to stop and come back at another time if we need to. So there’s nothing wrong with not accomplishing your first goal, you need to have more than one goal.” (participant 2)

Being creative and adaptive

“The decision-making is highly dynamic. And has to be. I mean, you need to accept at any stage that the goals have to be changed, that our strategy has to [be] changed.… The thinking process is developing during surgery.” (participant 7)

--

“I would say that it’s pretty rare that you ever have the same case, you know, over and over again or anything like that. There’s some routine to neurosurgery but everyone is a little bit different. And so you’re always having to learn and adapt and kind of, you know, change and tailor to what’s needed at the time. So I think you never really get bored.” (participant 4)

--

“I tell [medical students] to go do some handy work around the house. Just make things. Because it teaches you problem solving. How do things fit together? What do I do in this situation where I don’t have—how do I fit these two pieces of wood together? All those kinds of things that teach people about problem solving.” (participant 13)

--

“No human being is the same as the others. There are so many different things during surgery that require creativity.” (participant 6)

Being systematic

“I think one has to try to make decisions about what risks are worth taking in as dispassionate manner as possible.” (participant 13)

--

“You suppress the adrenaline so that you can continue to be analytical about it. And calmly rational about how to manage the circumstance.” (participant 22)

--

“The bad thing is your experience has a tendency to say, ‘Well, last time I did that it turned out, so I’m gonna do B instead.’ And then you deal with an N of one or an N of two or an N of three. And you might say, as a scientist, ‘Well, is that a really good scientific method that you went on—We had one bad outcome out of 400 and now you change your whole practice parameters so that you do different stuff.…’ But in the end, you’re constantly refining what you’re doing and trying to do better. So that’s just what you’re supposed to do as a surgeon.” (participant 2)

--

“Any information intraoperatively that I can get scientifically, such as from the pathologist, such as from intraoperative monitoring … will help me make that decision intraoperatively.” (participant 20)

Working on teams

“Another way of solving the problems is, of course, to ask the assisting of a neurosurgeon. ‘What do you think, do we have an idea? Did I make something wrong, have I overlooked something, what’s your impression of it?’ This is very, very important, because … nearly all surgeries are performed with an assistant.” (participant 10)

--

“My former colleagues and I functioned more as a team than ‘my patient—your patient.’ So most surgical decisions beyond the simplest were discussed as a team before the surgery started and there were many times each of us invited one of the other of us into the room, just to get a real-time interpretation of findings, to run a decision by before doing something foolish. I think that was a great culture that we established while I was there and … took advantage of how divergent our experience and years and training were. So—the net result is I think it made all of us better surgeons by not letting ego stand in the way of good judgment.” (participant 12)

--

“I’m usually operating with somebody else; I typically operate with a fellow who’s a sort of a very senior trainee and there’s a lot of back and forth between us. So we’ll be sort of troubleshooting together, and I’ll want their feedback and see if they have any other ideas of things that I might have missed.… We do a lot of monitoring during the operation … and relying on the technologists, who are running that … we work together a lot and I think we know each other well enough that we can work through scenarios.” (participant 21)

Patient and caregiver practiceShared decision-making

“I’m very much a proponent of getting families on board and setting expectations and helping them make a decision, but letting the decision be theirs ultimately. I usually talk to families beforehand about—in this type of tumor when I think it’s going to be an ependymoma. Just give them a sense of the risks and then the importance of resection and ask them how comfortable they are with accepting that tracheostomy and ventilator and breathing tube that’s permanent, for many months for their child.” (participant 8)

--

“One has to really try to take the cue from the parents as much as possible. Which in some circumstances is doable as possible. In some circumstances, it isn’t, because the parents themselves are struggling and they don’t have the capacity to help you with the kids. We’re trying to help them make decisions. So of course we want to avoid any top-down decisions. So we try to get the parents, in particular, involved in all the decisions that we make. We make joint decisions with the parents. But in that, of course, there’s a range.” (participant 13)

--

“Part of that preoperative discussion is also me gauging the family’s risk tolerance and laying out, you know, various potential scenarios. Because sometimes there’s a choice, right, so I could be more aggressive about an operation, but you have to understand this is the added risk that comes with that. But I think it’s also reasonable to be less aggressive, lower risk, but we may have to do more surgery at some other time—type thing. So, families have different levels of tolerance and so they certainly play into my mind preoperatively when we have these types of discussions.” (participant 21)

--

“There are parents that are risk averse. And I listen to the parents carefully and we discuss this beforehand. Um, there are some parents that say to me, ‘At any cost, take it all out. Okay, we can tolerate the deficits.’ And there are other parents that just say, ‘Look, I love my child too much. Do not leave them wrecked. Do the best you can, without doing that. I know it’s a risk.’ So parents matter. Especially in pediatrics.” (participant 15)

Seeing the whole patient

“I think the human aspect of what we do is a little bit more important than the technical aspect. For example, you want a balance between the postoperative MRI scan and the patient. If the postoperative MRI scan looks perfect, and the patient looks terrible, why is that a good outcome?” (participant 3)

--

“You do have to keep in mind that there’s a person beneath those six square centimeters that you’re looking at. You don’t want to become so impersonal about it, which is a tendency you tend to have when you’re a trainee. When you’re a trainee, it’s all about the tactical thing you’re doing, you forget the patient.… You have to learn to do that balance.” (participant 1)

--

“When I operate [on] the child, of course, I think about how … the child [will] grow up, but after the operation, the parents take care of the child.… But some children don’t have parents or … they’re so poor, and at the time, I think, after the operation, what we should do. So for me, the treatment for the child is not only the operation, but also after operation. For example, when I remove the tumor, I want to remove the tumor completely, but sometimes the tumor is adhering, so I cannot remove it. Ten years later, maybe … the technology is changing, … so we can cure the tumors. And also during that 10 years, the parents have their child. So, for me, the parents is a very important factor.” (participant 16)

--

“I think about the patient. Doesn’t matter if he’s a newborn or 10 or 15 years old—I try to think of himself or herself. What is better for her, for him, like a human being, [how] he or her are experiencing this situation.” (participant 18)

Surgeon practiceCultivating self-awareness

“I’ve had this philosophy about medical malpractice that it’s not a single act. It’s not that I cut here when I should have cut there. It’s really a cascade of missed opportunities and misjudgments. If you always are being introspective, and you’re saying, ‘Okay, something’s going wrong, what have I done wrong?’ You can break that cascade.” (participant 1)

--

“You also have to be good at taking things seriously but not overthink too much, otherwise you just get paralyzed and you don’t go on. And don’t carry on. It’s easy to forget the bigger picture, which is, you want the patient to be at least not worse than before. And that requires, at least for me, a sort of an active effort.” (participant 17)

--

“Good judgment comes from your learning from your own experiences—a detailed analysis of every scenario that you’re going through—and from attitude. You need to have that good will, you know. Especially in a medical scenario, you need to have good will, then only you will work on your experiences, then only you try to work hard on your knowledge.” (participant 7)

--

“It’s a Hasidic story … Rabbi Bunim, I think, … would tell this opposing truths that, everyone should have two pieces of paper. One should say, ‘For me, for my sake, was the world created.’ And then the other piece of paper should say, ‘I am but dust and ashes.’ And you should keep them in two different pockets. And periodically, you need to take one out and read it and the key is knowing when to take out each one. So, I think as neurosurgeons or as doctors in general, we live on this tense fault line where we have to go in thinking that we’re God, but we also have to be incredibly humble. And know when it’s not about us. So we couldn’t do what we did, if we weren’t incredibly confident, but you have to know when to pull back and when it’s not about you.” (participant 3)

Learning from experience

“You think about, ‘Did I make the right procedure? Did I make the right decisions? Would it have been better to do it otherwise or so?’ These were exceptional cases. But then of course, you think about this: ‘Was that the best way to do it? Would I do it once more this way in another patient or would I do it a different way with the next patient?’ “ (participant 10)

--

“[Response to uncertainty in the OR is] similar to your personal response to uncertainty in your everyday life. So if you’re not a traveler and when you’re traveling your flight is delayed and you’re going to miss your next flight, the first time that happens, your experience of it is very, very different than the 90th time that happens.… Okay, well stuff happens and you like, I’m pretty good at dealing with stuff and I dealt with it the last 89 times and I’m going to deal with it the 90th time. So it does, it does evolve a little bit gradually over time.” (participant 5)

--

“This patient [who had a bad outcome]—you really have [them] in mind. So this patient, I think, follows you the whole life. So it’s something that you think, ‘Ah, it was this guy where this happened. So don’t do that anymore.’ [laughs] So, I think, yeah, because when something bad happens in the brain, or in the spine—[for example] this guy who had this bladder problems, [it] was a really bad feeling for me. And I think nowadays I would have left this thing there.” (participant 11)

--

“We think about [a bad outcome] as a mistake postop in sort of a heuristic way, because we learn from this.… In retrospect, it’s an error. And I feel comfortable calling it that, because it might inform my next case, right, maybe there’s something there that I can learn from the next time.… I can then say, ‘Well, when I was in this particular geographical area last time anatomically, it didn’t go so well, maybe next time I won’t do that.’ “ (participant 21)

Professional Practice

Preparing for Uncertainty

One of the most important philosophical beliefs that was reported regarding intraoperative decision-making was to try to avoid this situation by preparing for surgery in advance. Preparing in advance could involve reviewing scans and other diagnostic information in advance of surgery, rehearsing the surgery in their minds, and most importantly, trying to anticipate in advance what uncertainties and complications might arise and having a plan in place to deal with each of these potential scenarios. One surgeon described this process as follows:

A big part of making difficult decisions, is anticipating what difficult decisions you may need to make. And anticipating where the problems are so that you don’t have to make difficult decisions. And work really hard in terms of thinking through all the scenarios and what one will encounter so that there aren’t any surprises. It should be very, very, very few instances in neurosurgery where you are truly, truly surprised. If you’re surprised, then the chances are that you missed something. You make a preoperative decision about how far you will push the tumor, with a certain threshold of motor evoked potentials beyond or below which you’d stop the operation. So as much as possible one kind of de-emphasizes the weighing up of decisions during the operation by having a very clear operative goal about what are the thresholds that are going to stimulate certain decisions. (participant 13)

Doing No Harm

In line with the Hippocratic Oath, the main guiding principle regarding decision-making for neurosurgeons when encountering an uncertainty or a complication while operating was to consider the safety of the patient. The notion of safety was nuanced and encompassed whether to proceed at all and/or how to proceed when it appeared that the child’s life might be in danger. Safety also included considerations of how each decision the surgeon made in these circumstances during surgery might affect the long-term quality of life of the child in terms of deficits or long-term damage. On this, one surgeon remarked: “The way I come to make a decision is first make sure that you do no harm. And try to get out of the situation, creating the least amount of damage. That’s the basic principle by which you go” (participant 9). The principle of doing no harm was especially salient when surgeons considered whether to abort a surgery. On this, another surgeon remarked: “If I feel I will hurt the patient or change the patient’s life in a bad way, you know, of course, that idea will stop me. If I feel like, you know, stopping the surgery would be more beneficial to the patient, I would not hesitate to stop” (participant 20).

As part of safety considerations, surgeons, particularly those with more years of experience, reported that this basic philosophy of doing no harm included the notion that it is always preferable to come back a second or even third time to an operation than to proceed if there is uncertainty about whether the procedure can be completed safely. On this, one surgeon noted:

The main focus we have while doing operation is first of all the safety of the patient. If we can stop this operation and do another operation later, that would be better than [to] do it at the right time but have complications or hemorrhage or whatever. So they make the operation safe for the patient and divide [in]to parts if possible. (participant 14)

Being Creative and Adaptive

Surgeons emphasized that neurosurgery, particularly in young children, is a dynamic and an evolving field. They described neurosurgery as a unique profession in which no surgery is routine because each individual is unique in their anatomy and their pathology. As such, a guiding philosophy regarding intraoperative decision-making involved developing creativity and adaptability as surgical traits to aid in making decisions when encountering something unexpected, uncertain, or complicated. One participant described this capacity as “liquid intelligence.” They noted:

We still have to remember, particularly in surgery, that each individual is just that—they’re an individual. There are variations that will always fall outside the parameters, the paradigm, and you have to have that liquid intelligence, that ability to quickly shift and say, “Okay this is not following the algorithm, you know, I can’t do it this way. What am I thinking wrong?” (participant 1)

Another surgeon similarly remarked:

Part of what we do and one of the skill sets as a neurosurgeon is that you need to be creative and be able to come up with ways to get around things. It’s not uncommon that we’re missing a part in the OR for some of that fancy equipment. Or something doesn’t work the way it’s supposed to. You have to come up with a plan. You’re constantly revising, improving, thinking about what to do. (participant 2)

Being Systematic

While cultivating creativity and adaptability was important to surgeons, they also noted that it is equally essential to develop systematic, empirical, and analytical thinking skills to aid in making decisions during surgery. On this, one surgeon explained: “Decision-making is also something related to empirical knowledge. And if you collect this, this is the biggest treasure also for future problem solving” (participant 23). Another similarly explained: “Surgeons are taught in this very deliberate differential diagnosis way to immediately create a laundry list of possible issues. And then take in information. And essentially refute or fail to refute some of those possible issues on the laundry list” (participant 5).

Working on Teams

Neurosurgeons described teamwork as a particularly important component of intraoperative decision-making and noted that this approach was unique to pediatrics. As one surgeon remarked: “The most important part of a neurosurgical service is the culture. It’s incumbent upon the leadership to create a culture of collaboration” (participant 15). This “culture of collaboration” as a philosophy aided neurosurgeons in making decisions that rely on both the entire neurosurgical team, which included other healthcare professionals, and especially other pediatric neurosurgeons who frequently consult during surgery. On this, one surgeon reported:

I would say that the main factor which influences my decision-making is first of all the work in teamwork. I always consult with my colleagues, which are neurophysiologists, neuropsychologists, anesthesiologists. Usually we discuss our case during surgery—discuss when I will stop. I want their approval that they agree that, for example, I didn’t forget—we didn’t forget to remove that part of the tumor and so on. (participant 14)

Patient and Caregiver Practice

Shared Decision-Making

Surgeons described spending a great deal of time with families in advance of surgery in order to manage their expectations about the potential risks inherent in the procedures and to engage in a shared decision-making process with them that ultimately guided the surgeons’ intraoperative decisions. These presurgery discussions involve clarifying with the family (and when relevant, an older patient) what their values are, how tolerant of risk they are, and what their goals are for the operation. These desires then shaped decisions that had to be made during the surgery. For example, one surgeon described a process of gauging the risk tolerance of a family, which they then used to guide decisions in the operating room (OR). The surgeon noted:

So a detailed interview in the beginning of the surgery or the day before the surgery or previous meetings with the parents helps us to understand what kind of goals they have, what kind of understanding they have. How motivated they are. So multiple patient and parental inputs do make and guide us, you know, for, as a next step. (participant 7)

Seeing the Whole Patient

Thinking about the patient holistically was a robust theme where surgeons described the tremendous importance of weighing all intraoperative decisions in the context of the particular child they are operating on. As one surgeon remarked: “You should always love your patient more than you hate the disease” (participant 15). By this they meant that removing the entire tumor was less important than thinking about the impact of that surgery on the child’s life postsurgery. Partly this theme overlapped with the notion of doing no harm, but extended beyond it to thinking about the whole child and how to help them thrive. On this, one surgeon remarked:

The goal is not a technical one. But human one. This is a holistic view. Our goal is not to take out the tumor, to treat the hydrocephalus, to do this or to do that. This is the patient, he has complaints, and our task is to do him something good, to help him. (participant 10)

This theme also encompassed thinking about the child within their socioeconomic context and their access to healthcare when making decisions. Because this was an international study, some surgeons interviewed around the globe described situations where children could not afford postoperative care or would not have the resources they needed to recover from certain surgical procedures. This approach was not mentioned in North American or in European contexts, but came up frequently in other parts of the globe. The awareness of these children’s social circumstances guided intraoperative decisions that would maximize the likelihood that the child would survive and have minimal deficits within the resource constraints of their social context. On this one surgeon noted: “You might have a situation where the family is financially stressed out, non–insurance-covered, [and] then I know I should not take too much of a risk of creating more morbidity” (participant 7). Similarly, another surgeon reported:

You have to make certain decisions which are based on the social structure, the family structure of the patient. I think if the family is not likely to be able to support a child who becomes, say, hemiplegic, paralytic on one side then you probably decide that it is better to leave a little bit of tumor rather than making this child handicapped, even if it is only for a few months, because the child may not be looked after. So yes, there are certain decisions like this you have to make. (participant 9)

Surgeon Practice

Cultivating Self-Awareness

Surgeons reported that as a practice, they worked on cultivating self-awareness in order to ensure they were making good intraoperative decisions that are based on good reasoning rather than on ego or other unsound foundations. In the context of making the difficult decision to abort a surgery, one surgeon remarked:

One goes through the internal process of constantly thinking about what your motivation is—either your motivation to stop or your motivation to continue. And then being constantly self-aware about how your own emotional, psychological state can get in the way there. So I think probably the best term is just self-reflection and self-awareness—knowing exactly all the things that are influencing your ability to make a clear, objective assessment of the situation and therefore the decision that emanates from that. (participant 13)

Another surgeon described a similar practice that is an ongoing part of being a neurosurgeon: “There has to be an element of self-knowledge. You have to look inward and know your limit, your intellectual limit, your surgical skills. It’s like this inner talk that is saying, ‘Okay, if I keep doing this, am I going to hurt him? You going to end up paying the price? Do I have a better alternative? Do I stop?’ And this is constant, this is ongoing” (participant 6).

Learning From Experience

A related theme to cultivating self-awareness involved the practice of constantly learning from previous experiences, including mistakes, in order to make better intraoperative decisions in the future. Surgeons described learning from their experiences as a lifelong practice that profoundly impacted subsequent decisions in the OR. Learning from experience could involve rethinking procedures after they have been completed in order to learn from them, or going step by step through operations that did not go well to try to assess what went wrong. One surgeon, for example, described recording most of his procedures in order to review them later:

In most of my procedures, I do record them. And then I go back, and see what is going on. And then I try to learn from what I could have done differently. So sometimes you say, ‘Okay, I did this and things didn’t go right. Why didn’t they go right?’ So that’s when the next time you’re pleased with that choice, it should be not a gut call but, a choice made on the analysis of the previous case. (participant 6)

Another surgeon discussed the need to learn from previous experiences where things did not go well that leave a particularly strong impact on approaches to intraoperative decision-making in the OR. For example, this surgeon explained: “There are times where early in the career, the envelope is pushed too far and patients have an injury from that. And those are lifelong, career-long lessons which affect everything else that is done for the rest of time” (participant 12).

Discussion

This study explored pediatric neurosurgeons’ approaches to decision-making when they encounter unexpected events, uncertainties, or complications while operating on children. This research is critically important because making intraoperative decisions is a routine part of the work that pediatric neurosurgeons do, yet it is a profoundly understudied phenomenon that may lead to subpar decisions that can affect patient safety.8 Moreover, pediatric neurosurgery is a complex undertaking where the safety margins are narrow. As such, poor intraoperative decisions can have dire consequences, including significant morbidity for children and in some cases death.

Despite the fact that decision-making is one of the most important skills a surgeon can have, decision-making during surgery is a poorly understood phenomenon, and therefore may not be adequately or systematically taught to surgeons in training.3,11,12 The dominant decision-making theories discuss intuitive or analytical strategies,2,4 which can be opaque to surgeons who are observing these procedures in action. That is, the vast majority of surgeons learn by watching a more senior surgeon do procedures, but do not have access to the operating surgeons’ thinking process as they work through unexpected events, complications, and uncertainty while operating. In one paper on managing intraoperative stress, general, cardiothoracic, trauma, and orthopedic surgeons were interviewed about their experiences of stress in the OR. While this paper was not specifically on decision-making, the findings are relevant to the current research in that it partly focused on the relationships between intraoperative stress and its impact on decision-making. One participant in that study explained:

The whole persona of the surgeon is somebody who can make decisions and cope with anything. Except when things go wrong … then that same person can’t think straight, makes mistakes, and loses all judgment—everything descends into chaos and patient care is seriously compromised.12

The authors of this study concluded that there is a dire need for structured training in managing intraoperative stress in order to increase the safety of the patient and to improve surgical performance.13

The findings in our study revealed that pediatric neurosurgeons have a structured, well-thought-out analytical philosophy and practice regarding intraoperative decision-making. Interestingly, however, many of the surgeons interviewed for this research reported that they had never thought about these questions before and did not think about their decision-making practice as constituting a coherent philosophy before taking part in the interview. Moreover, these approaches and philosophies were not directly taught to them in a formal way during their own training. Each surgeon was left on their own to develop these approaches in an ad hoc way, leading some to have extensively developed approaches, and some with only a cursory approach to dealing with these issues. The surgeons’ reflections on the novelty of the interview questions correspond to a striking dearth of scientific literature on the thought processes of pediatric and adult neurosurgeons generally, and on decision-making in the OR specifically. As such, one particularly significant implication of this research is the development of training modules based on these findings that outline a comprehensive, diverse, and coherent philosophy used by pediatric neurosurgeons who have developed their thinking and approaches to intraoperative decisions over time. The findings from this research begin to create a pedagogical archive of the philosophical approaches that pediatric neurosurgeons use in making intraoperative decisions. Although having hands-on experience in making intraoperative decisions is critical to learning good judgment, the philosophical approach outlined in our findings can be taught to residents in training. These strategies and approaches can be emulated by residents in training and complement the current practice of learning by watching and/or doing. This type of structured learning may lead to a faster learning curve, improving the surgeon’s ability to cope with the unexpected and, in the process, improve patient safety.

Limitations

Participants in this study were recruited via direct contact from the collaborators, who are pediatric neurosurgeons themselves, and through snowball sampling. As such, the sample did not consist of a random selection of pediatric neurosurgeons from around the globe. Moreover, whereas the purpose of a qualitative study is to understand the breadth and depth of a phenomenon, particularly one that has not been researched before, further research might use quantitative methods in order to sample a larger population of neurosurgeons.

Conclusions

Pediatric neurosurgeons have a structured, diverse, well-thought-out analytical philosophy and practice regarding intraoperative decision-making that encompasses a range of philosophical approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment when operating on children.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Granek, Roth. Acquisition of data: Granek, Constantini, Roth. Analysis and interpretation of data: Granek, Shapira. Drafting the article: Granek, Shapira, Roth. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Granek. Administrative/technical/material support: Granek, Shapira. Study supervision: Granek.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

References

  • 1

    Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med. 2007;82(10)(suppl):S109S116.

    • Search Google Scholar
    • Export Citation
  • 2

    Pauley K, Flin R, Yule S, Youngson G. Surgeons’ intraoperative decision making and risk management. Am J Surg. 2011;202(4):375381.

  • 3

    Cristancho SM, Vanstone M, Lingard L, et al. . When surgeons face intraoperative challenges: a naturalistic model of surgical decision making. Am J Surg. 2013;205(2):156162.

    • Search Google Scholar
    • Export Citation
  • 4

    Flin R, Youngson G, Yule S. How do surgeons make intraoperative decisions?. Qual Saf Health Care. 2007;16(3):235239.

  • 5

    Jacklin R, Sevdalis N, Darzi A, Vincent C. Mapping surgical practice decision making: an interview study to evaluate decisions in surgical care. Am J Surg. 2008;195(5):689696.

    • Search Google Scholar
    • Export Citation
  • 6

    Nugent W. Decision support in clinical practice: guidelines, pathways, algorithms, protocols and risk stratification. In: Manuel B, Nora P, eds.Surgical Patient Safety.American College of Surgeons;2004.

    • Search Google Scholar
    • Export Citation
  • 7

    McIntyre RC, Schulick RD. Surgical Decision Making E-Book. 6th ed. Elsevier Health Sciences;2019.

  • 8

    Roth J, Constantini S. Aborting a neurosurgical procedure: analyzing the decision factors, with endoscopic third ventriculostomy as a model. Childs Nerv Syst. 2020;36(5):919924.

    • Search Google Scholar
    • Export Citation
  • 9

    Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Research. Sage;2006.

  • 10

    Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Inquiry. Aldin;1967.

  • 11

    Cristancho SM, Apramian T, Vanstone M, et al. . Understanding clinical uncertainty: what is going on when experienced surgeons are not sure what to do?. Acad Med. 2013;88(10):15161521.

    • Search Google Scholar
    • Export Citation
  • 12

    Arora S, Sevdalis N, Nestel D, et al. . Managing intraoperative stress: what do surgeons want from a crisis training program?. Am J Surg. 2009;197(4):537543.

    • Search Google Scholar
    • Export Citation
  • 13

    Klaassen Z, Arora K, Wilson SN, et al. . Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening. Urol Oncol. 2018;36(2):6066.

    • Search Google Scholar
    • Export Citation

Supplementary Materials

Images from Szuflita et al. (pp 28–33).

Contributor Notes

Correspondence Leeat Granek: York University, Toronto, ON, Canada. leeatg@yorku.ca.

INCLUDE WHEN CITING Published online May 14, 2021; DOI: 10.3171/2020.12.PEDS20912.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med. 2007;82(10)(suppl):S109S116.

    • Search Google Scholar
    • Export Citation
  • 2

    Pauley K, Flin R, Yule S, Youngson G. Surgeons’ intraoperative decision making and risk management. Am J Surg. 2011;202(4):375381.

  • 3

    Cristancho SM, Vanstone M, Lingard L, et al. . When surgeons face intraoperative challenges: a naturalistic model of surgical decision making. Am J Surg. 2013;205(2):156162.

    • Search Google Scholar
    • Export Citation
  • 4

    Flin R, Youngson G, Yule S. How do surgeons make intraoperative decisions?. Qual Saf Health Care. 2007;16(3):235239.

  • 5

    Jacklin R, Sevdalis N, Darzi A, Vincent C. Mapping surgical practice decision making: an interview study to evaluate decisions in surgical care. Am J Surg. 2008;195(5):689696.

    • Search Google Scholar
    • Export Citation
  • 6

    Nugent W. Decision support in clinical practice: guidelines, pathways, algorithms, protocols and risk stratification. In: Manuel B, Nora P, eds.Surgical Patient Safety.American College of Surgeons;2004.

    • Search Google Scholar
    • Export Citation
  • 7

    McIntyre RC, Schulick RD. Surgical Decision Making E-Book. 6th ed. Elsevier Health Sciences;2019.

  • 8

    Roth J, Constantini S. Aborting a neurosurgical procedure: analyzing the decision factors, with endoscopic third ventriculostomy as a model. Childs Nerv Syst. 2020;36(5):919924.

    • Search Google Scholar
    • Export Citation
  • 9

    Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Research. Sage;2006.

  • 10

    Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Inquiry. Aldin;1967.

  • 11

    Cristancho SM, Apramian T, Vanstone M, et al. . Understanding clinical uncertainty: what is going on when experienced surgeons are not sure what to do?. Acad Med. 2013;88(10):15161521.

    • Search Google Scholar
    • Export Citation
  • 12

    Arora S, Sevdalis N, Nestel D, et al. . Managing intraoperative stress: what do surgeons want from a crisis training program?. Am J Surg. 2009;197(4):537543.

    • Search Google Scholar
    • Export Citation
  • 13

    Klaassen Z, Arora K, Wilson SN, et al. . Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening. Urol Oncol. 2018;36(2):6066.

    • Search Google Scholar
    • Export Citation

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