The Anatomy of the Surgeon’s Decision-Making

  • Rifat LatifiEmail author


Some of the most important elements of any surgical procedure are the decisions that the surgeon makes before, during, and after the surgery itself. Yet, the process of how surgeons make these decisions has not been studied adequately. Despite its enormous significance and regardless of the implications that this decision-making process has on surgical outcomes, the subject has received minimal attention in the literature. Subsequently, there are only a few studies that investigate how these decisions are made, although these decision-making processes are of great importance both for training and patient safety purposes. Often, surgeons have difficulty in describing exactly how they came to specific decision during surgery. Some describe these decisions as “intuition” or “gut-level” responses. Additionally, many factors affect decision-making abilities of surgeons during operations. These factors are the physiologic state of the surgeon, teamwork, external pressures at work, and the surgeon’s ability to adapt quickly to a changing environment, to name only a few. Yet, the question remains, how to perform an evaluation of the surgical decision and gaining a better understanding of a seemingly gut-level process, which helps surgeons combat the external factors experienced before and during surgery? This chapter will attempt to dissect further multiple factors that may explain further how surgeons make decisions.


Anatomy of surgical decision Physical factors Personality factors Situational awareness 



There are no identifiable conflicts of interests to report.

The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript.

The author would like to thank Elizabeth Teilly, PhD for her contributions to this chapter.


  1. 1.
    Latifi R. Surgical decision-making process: more questions than answers. Scand J Surg. 2013;102(3):139–40.CrossRefPubMedGoogle Scholar
  2. 2.
    Abernathy C, Hamm R. Surgical intuition. What it is and how to get it. Philadelphia: Hanley & Belfus; 1995.Google Scholar
  3. 3.
    Gawande A. The checklist manifesto: how to get things right. New York: Metropolitan Books, Henry Holt and Company, LLC; 2009.Google Scholar
  4. 4.
    Weinstein MC, Fineberg HV, Elstein AS, et al. Clinical decision analysis. Philadelphia: WB Saunders; 1980.Google Scholar
  5. 5.
    Mitchell L, Flin R, Youngson G, Malik M, Ahmed I. Intraoperative surgical decision-making: a video study. International conference on naturalistic decision making. Marseille, France; 2013.Google Scholar
  6. 6.
    Moulton C, Regehr G, Lingard L, Merritt C, Macrae H. Slowing down when you should: initiators and influences of the transition from the routine to the effortful. J Gastrointest Surg. 2010;14:1019–26.CrossRefPubMedGoogle Scholar
  7. 7.
    Massarweh N, Devlin A, Gaston SR, Broeckel EJ, Flum D. Risk tolerance and bile duct injury: surgeon characteristics, risk taking preference, and common bile duct injuries. Am J Surg. 2009;209:17–24.CrossRefGoogle Scholar
  8. 8.
    Dekker S, Hugh TB. Laparoscopic bile duct injury: understanding the psychology and heuristics of the error. ANZ J Surg. 2008;78:1109–14.CrossRefPubMedGoogle Scholar
  9. 9.
    Endsley MR. Towards a theory of situation awareness in dynamic environments. Hum Factors. 1995;37:32–64.CrossRefGoogle Scholar
  10. 10.
    Endsley MR. A survey of situation awareness requirements in air-to-air combat fighters. Int J Aviat Psychol. 1993;3:157–68.CrossRefGoogle Scholar
  11. 11.
    Endsley MR. Measurement of situation awareness in dynamic systems. Hum Factors. 1995;37:65–84.CrossRefGoogle Scholar
  12. 12.
    Endsley MR. The application of human factors to the development of expert systems for advanced cockpits. In Proceedings of the 7th international symposium on aviation psychology. Columbus: Ohio State University; 1987. p. 167–71.Google Scholar
  13. 13.
    Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors J Hum Factors Ergon Soc. 1995;37:20–33.CrossRefGoogle Scholar
  14. 14.
    Durso FT, Sethumadhavan A. Situation awareness: understanding dynamic environments. Hum Factors J Hum Factors Ergon Soc. 2008;50:442–50.CrossRefGoogle Scholar
  15. 15.
    Shah H, Hamid ABD, Waterson P, Hignett S. Situation awareness to support decision-making among emergency care practitioners. In Proceedings of NDM9, the 9th international conference on naturalistic decision-making, London, UK; June 2009.Google Scholar
  16. 16.
    Flin R, Youngson G, Yule S. How do surgeons make intraoperative decisions? Qual Saf Health Care. 2007;16:235–9.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Wood G, Batt J, Appelboam A, Harris A, Wilson MR. Exploring the impact of expertise, clinical history, and visual search on electrocardiogram interpretation. Med Decis Mak. 2014;34:75–85.CrossRefGoogle Scholar
  18. 18.
    Kundel HL, Nodine CF, Krupinski EA, Mello-Thoms C. Using gaze-tracking data and mixture distribution analysis to support a holistic model for the detection of cancers on mammograms. Acad Radiol. 2008;15(7):881–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons’ non-technical skills. Med Educ. 2006;40:1098–104.CrossRefPubMedGoogle Scholar
  20. 20.
    van Gaal S, Lamme VAF. Unconscious high-level information processing: implication for neurobiological theories of consciousness. Neuroscientist. 2012;18:287–303.CrossRefPubMedGoogle Scholar
  21. 21.
    Cowey A. The blindsight saga. Exp Brain Res. 2010;200:3–24.CrossRefPubMedGoogle Scholar
  22. 22.
    Tamietto M, Castelli L, Vighetti S, Perozzo P, Geminiani G, Weiskrantz L, et al. Unseen facial and bodily expressions trigger fast emotional reactions. Proc Natl Acad Sci U S A. 2009;106:17661–6.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Tamietto M, de Gelder B. Neural bases of the nonconscious perception of emotional signals. Nat Rev Neurosci. 2010;11:697–709.CrossRefPubMedGoogle Scholar
  24. 24.
    Lamme VAF, Roelfsema PR. The distinct modes of vision offered by feedforward and recurrent processing. Trends Neurosci. 2000;23:571–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Breitmeyer BG, Ogmen H, editors. Visual masking: time slices through conscious and unconscious vision. Oxford: Oxford University Press; 2006.Google Scholar
  26. 26.
    Klotz W, Neumann O. Motor activation without conscious discrimination in metacontrast masking. J Exp Psychol Hum Percept Perform. 1999;25:976–92.CrossRefGoogle Scholar
  27. 27.
    Bush G, Luu P, Posner MI. Cognitive and emotional influences in anterior cingulate cortex. Trends Cogn Sci. 2000;4(6):215–22.CrossRefPubMedGoogle Scholar
  28. 28.
    Lane RD, Reiman EM, Axelrod B, Yun LS, Holmes A, Schwartz GE. Neural correlates of levels of emotional awareness. Evidence of an interaction between emotion and attention in the anterior cingulate cortex. J Cogn Neurosci. 1998;10(4):525–35.CrossRefPubMedGoogle Scholar
  29. 29.
    Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D, Youngson G. Surgeons’ non-technical skills in the operating room: reliability testing of the NOTSS behaviour rating system. World J Surg. 2008;32:548–56.CrossRefPubMedGoogle Scholar
  30. 30.
    Chatterjee S, Ng J, Kwan K, Matsumoto E. Assessing the surgical decision making abilities of novice and proficient urologists. J Urol. 2009;181:2251–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of SurgeryWestchester Medical Center, New York Medical CollegeValhallaUSA
  2. 2.Department of SurgeryUniversity of ArizonaTucsonUSA

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