Surgical trainee decision making: Exploring, modelling, teaching and learning

Decision making is a key competency for surgeons and trainees; however, neither its key components, nor how it should be taught and assessed, are well understood in all surgical settings. Most surgical decision making research has investigated elements of decision making in elective, pre- and intra-operative settings. This thesis explores trainee surgical decision making in the acute setting, focusing on less controlled settings of the ward and emergency room. Using qualitative structured interviews found that trainees primarily described using naturalistic methods in contrast to previous hypotheses. They predominantly utilised pattern recognition, with patient appearance being one of their main cues. In contrast to descriptions of expert decision makers, they did not act quickly on their decisions, consider absent cues, or trial their decision with mental simulation. Trainees described many factors influencing decision making, indicating its complexity. From this a “surgical trainee decision making mind map” was developed. Criteria that defined good and poor decisions, decision makers and essential factors for developing decision making skills were developed from a qualitative survey of international experts in surgery, cognitive research and medical education. From this the following definition of a good decision maker was compiled. A good surgical decision maker is a surgeon or trainee who makes well informed and considered, timely, patient focused decisions which are backed by a sound knowledge and good evidence-base, while recognising their own limitations, the need for collaboration, reflection and clear communication to bring about an appropriate action. The “Global Surgical Decision Making Model” was created to assist conceptualisation of acute surgical decision making and compared to current decision models. The model was also validated. A surgical decision making (SDM) eLearning package was constructed to facilitate understanding and acquisition of SDM skills. This was presented to surgical trainees and medical students for evaluation, and to assess whether medical students could act as a surrogate for the trainees. The SDM eLearning package used the “Global Surgical Decision Making Model” as a framework. Evaluation of the SDM eLearning package contributed to validation of the model, achieved learning gains in understanding of SDM, and was well received by participants. A summary of the key findings of this thesis offering interpretation and implications of the main results, and recommendations for how research can be progressed in the future has been compiled. This thesis adds to the body of surgical decision making research by: • detailing surgical trainee decision making in the acute surgical setting; • illustrating the complexity of acute trainee decisions in the “surgical trainee decision making mind map”; • identifying criteria for distinguishing good and poor decision making and decision makers, and offering a definition of a good decision maker; • detailing factors that facilitate the development of decision making skills; • providing a new model to act as a framework for considering decision making as it applies to surgical trainees; • contributing a SDM eLearning package that can be incorporated into surgical decision making curricula for both surgical trainees and medical students