Science and art of decision-making in surgery

Surgeons come from different cultures, have different religious beliefs, work in varying health systems and resources and are ultimately guided by legal requirements of the country they work in. We link all of these factors by describing the science behind decisions, heuristics, cognitive processing and human factors. We discuss how surgeons interpret the risk of surgery to the patient but have to be conscious that they are also balancing the risk to themselves. The latter being an increasing consideration as surgical outcomes are reported according to key quality performance indices, such as anastomotic leak. The personality of the surgeon is explored finding not a ‘bad’ trait but traits that may respond suboptimally in certain circumstances. To overcome this, achieving ‘personality awareness’ is proposed.

Most surgeons would say that they learnt decision-making through experience in their day-to-day job, with few having had formal training within their surgical training programmes. Residents also describe indirect training and alongside a medical student, give us insights into the progression of decision-making from student to independent surgeon.

When things do not go as planned, we question our decisions and although often not wrong, we can have a strong and negative emotional response. We describe the difference between adverse events and errors and how both can lead to burnout. Human factors can cause both as a result of a longer term stress with the delicate interplay of the surgeon, hospital and job discussed. Mentoring or support programmes could play an important role.

Shared decision-making is key between the patient and the surgeon. Trust is at the forefront with open and transparent communicating. Our patients kindly describe aspects of their individual surgical experience and make suggestions for surgeons to consider.

Overall, the surgical community are likely to be unaware of how they make decisions. We hope that this BJS commission provokes individual and group reflection and discussion that challenges surgeons to unpack how they make decisions. With practical suggestions throughout this commission, surgeons have the opportunity to add new insights to their current decision-making skills.