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‘Slowing Down When You Should’: Initiators and Influences of the Transition from the Routine to the Effortful

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

‘Slowing down when you should’ has been described as marking the transition from ‘automatic’ to ‘effortful’ functioning in professional practice. The ability to ‘slow down’ is hypothesized as an important factor in expert judgment. This study explored the nature of the ‘slowing down’ phenomenon intraoperatively and its link to surgical judgment.

Methods

Twenty-eight surgeons across different surgical specialties were interviewed from four hospitals affiliated with a large urban university. In grounded theory tradition, data were collected and analyzed in an iterative design, using a constant comparative approach. Emergent themes were identified and a conceptual framework was developed.

Results

Surgeons recognized the ‘slowing down’ phenomenon acknowledging its link to judgment and described two main initiators. Proactively planned ‘slowing down’ moments were anticipated preoperatively from operation-specific (tying superior thyroid vessels) or patient-specific (imaging abnormality) factors. Surgeons also described situationally responsive ‘slowing down’ moments to unexpected events (encountering an adherent tumor). Surgeons described several influencing factors on the slowing down phenomenon (fatigue, confidence).

Conclusions

This framework for ‘slowing down’ assists in making tangible the previously elusive construct of surgical judgment, providing a vocabulary for considering the events surrounding these critical moments in surgery, essential for teaching, self-reflection, and patient safety.

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References

  1. Schön DA. The reflective practitioner: how professionals think in action. New York: Basic Books, 1983.

    Google Scholar 

  2. Schön DA. Educating the reflective practitioner: toward a new design for teaching and learning in the professions. San Francisco: Jossey-Bass, 1987.

    Google Scholar 

  3. Dreyfus HL, Dreyfus SE. Mind over machine. New York: Free, 1986.

    Google Scholar 

  4. 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):S109–S116.

    Article  PubMed  Google Scholar 

  5. Glaser B, Strauss A. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine, 1967.

    Google Scholar 

  6. Charmaz K. Grounded theory: objectivist and constructivist methods. In: Denzin N, Lincoln Y, eds. Handbook of qualitative research, 2nd ed. Thousand Oaks: Sage, 2000, pp 509–535.

    Google Scholar 

  7. Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory, 2nd ed. Thousand Oaks: Sage, 1998.

    Google Scholar 

  8. Morse J. The significance of saturation. Qual Health Res 1995;5:147–149.

    Article  Google Scholar 

  9. Kelle U. Computer-aided qualitative data analysis: theory, methods and practice. Thousand Oaks: Sage, 2002.

    Google Scholar 

  10. Moulton C, Regehr G, Lingard L, Merritt C, MacRae H. Operating from the other side of the table: control dynamics and the surgeon educator. J Am Coll Surg 2010;210:79–86.

    Article  PubMed  Google Scholar 

  11. Reason J. Safety in the operating theatre—part 2: human error and organisational failure. Qual Saf Health Care 2005;14(1):56–60.

    CAS  PubMed  Google Scholar 

  12. Carthey J, de Leval MR, Reason JT. Institutional resilience in healthcare systems. Qual Health Care 2001;10(1):29–32.

    Article  CAS  PubMed  Google Scholar 

  13. Reason JT, Carthey J, de Leval MR. Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management. Qual Health Care 2001;10(Suppl 2):ii21–ii25.

    PubMed  Google Scholar 

  14. Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360(5):491–499.

    Article  CAS  PubMed  Google Scholar 

  15. Lingard L, Regehr G, Orser B et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143(1):12–17.

    Article  PubMed  Google Scholar 

  16. Custers EJ, Regehr G, Norman GR. Mental representations of medical diagnostic knowledge: a review. Acad Med 1996;71(10 Suppl):S55–S61.

    CAS  PubMed  Google Scholar 

  17. Regehr G, Norman GR. Issues in cognitive psychology: implications for professional education. Acad Med 1996;71(9):988–1001.

    Article  CAS  PubMed  Google Scholar 

  18. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;10:S1–S12.

    Google Scholar 

  19. Kahneman D. Attention and effort. Englewood Cliffs: Prentice-Hall, 1973.

    Google Scholar 

  20. Cowan N, Elliot EM, Saults JS et al. On the capacity of attention: Its estimation and its role in working memory and cognitive aptitudes. Cogn Psychol 2005;51:42–100.

    Article  PubMed  Google Scholar 

  21. Simons DJ. Attentional capture and inattentional blindness. Trends Cogn Sci 2000;4(4):147–155.

    Article  PubMed  Google Scholar 

  22. Rensink RA, Oregan JK, Clark JJ. To see or not to see: the need for attention to perceive changes in scenes. Psychol Sci 1997;8(5):368–373.

    Article  Google Scholar 

  23. Evans JSBT. Dual-processing accounts of reasoning, judgment, and social cognition. Annu Rev Psychol 2008;59:255–278.

    Article  PubMed  Google Scholar 

  24. De NW, Glumicic T. Conflict monitoring in dual process theories of thinking. Cognition 2008;106(3):1248–1299.

    Article  Google Scholar 

  25. Burke K. A rhetoric of motives. Berkeley: University of California Press, 1969.

    Google Scholar 

  26. Lingard L, Haber RJ. Teaching and learning communication in medicine: a rhetorical approach. Acad Med 1999;74(5):507–510.

    Article  CAS  PubMed  Google Scholar 

  27. Endsley MR. Toward a theory of situation awareness in dynamic systems. Hum Factors 1995;37:32–64.

    Article  Google Scholar 

  28. Jones DG, Endsley MR. Sources of situation awareness errors in aviation. Aviat Space Environ Med. 1996;67(6):507–512.

    CAS  PubMed  Google Scholar 

  29. Franzese CB, Stringer SP. The evolution of surgical training: perspectives on educational models from the past to the future. Otolaryngol Clin North Am 2007;40(6):1227–1235, vii.

    Article  Google Scholar 

  30. Rosenthal DM. Consciousness and its function. Neuropsychologia 2008;46(3):829–840.

    Article  PubMed  Google Scholar 

  31. Koriat A. The feeling of knowing: some metatheoretical implications for consciousness and control. Conscious Cogn 2000;9(2 Pt 1):149–171.

    Article  CAS  PubMed  Google Scholar 

  32. Kentridge RW, Heywood CA. Metacognition and awareness. Conscious Cogn 2000;9:308–312.

    Article  CAS  PubMed  Google Scholar 

  33. Mandler G. The consciousness continuum: from “qualia” to “free will”. Psychol Res 2005;69(5–6):330–337.

    Article  PubMed  Google Scholar 

  34. Regehr G, Eva K. Self-assessment, self-direction, and the self-regulating professional. Clin Orthop Relat Res 2006;449:34–38.

    PubMed  Google Scholar 

  35. Epstein RM, Siegel DJ, Silberman J. Self-monitoring in clinical practice: a challenge for medical educators. J Contin Educ Health Prof 2008;28(1):5–13.

    Article  PubMed  Google Scholar 

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Acknowledgments

This study was supported by a grant from Physicians Services Incorporated Foundation.

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Authors and Affiliations

  1. Wilson Centre for Research in Education, Toronto General Hospital, 10-212, 200 Elizabeth St, Toronto, ON, Canada, M5G2C4

    Carol-anne Moulton, Glenn Regehr, Lorelei Lingard & Catherine Merritt

  2. Department of Surgery, University of Toronto, Toronto, ON, Canada

    Carol-anne Moulton & Helen MacRae

Authors
  1. Carol-anne Moulton
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  2. Glenn Regehr
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  3. Lorelei Lingard
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  4. Catherine Merritt
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  5. Helen MacRae
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Corresponding author

Correspondence to Carol-anne Moulton.

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Moulton, Ca., Regehr, G., Lingard, L. et al. ‘Slowing Down When You Should’: Initiators and Influences of the Transition from the Routine to the Effortful. J Gastrointest Surg 14, 1019–1026 (2010). https://doi.org/10.1007/s11605-010-1178-y

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  • DOI: https://doi.org/10.1007/s11605-010-1178-y

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