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Surgical Judgement:

SUMMONING COGNITIVE RESOURCES

Carol-anne Moulton
Carol-anne Moulton
Carol-anne Moulton's MEd research focused on how we teach technical skills to residents, comparing "massed practice" -- teaching skills all at once in an intensive course -- to "distributed practice" -- training a little bit each week. The distributed practice worked better. An interest in surgical judgement was fostered during the time she spent in the Wilson Centre with frequent impromptu discussions with Glenn Regehr and Helen MacRae. Judgement has become the focus of her doctoral research. She feels that we can improve the way surgical judgement is taught. Because they make decisions at 600 mph, fighter pilots in training spend 15 hours in preparation and debriefing for every hour in flight. From both an operational and a teaching point-of-view, it would be valuable to both residents and faculty to spend more time on preoperative mental rehearsing, imaging and planning, and to debrief postoperatively.

To improve teaching surgical judgement, we must first understand it, so Carol-anne became interested in deconstructing what is actually meant by the term. Surgeons use many words -- decision-making, clinical reasoning, problem- solving, judgement, clinical acumen and intuition -- to describe what they are actually doing when they are making the right decisions for their patients. The surgeons she has interviewed find it difficult to describe what they mean by good surgical judgement, but they know it when they see it in a surgical resident.

In order to deconstruct what it is that surgeons "see", she observed hepatobiliary surgeons in the operating room. She concludes that it comes down to "the moment of slowing down when you should", a metaphor for focusing, for summoning additional cognitive resources. She is currently interviewing surgeons about what they experience in those "slowing down" moments when there is a transition from automatic to effortful mode.

Part of slowing down when you should is recognizing that there is an issue to be addressed, what Carol-anne calls "situation awareness". There are three levels of situation awareness: one, perception of stimuli (radar blips); two, understanding the stimuli (enemy planes); and three, projection of what this will mean in the future (call for help).

Decision-making follows this picturing of the environment. A bad decision is often the result of having a poor picture of the environment, rather than poor decision-making skills. Most errors in the aviation industry are not decision-making errors, but errors in situation awareness.

Carol-anne observes that we usually don't allow residents to reach that uncomfortable feeling when there is a problem, through their own situation awareness. Instead of allowing residents to slow down and work things through, faculty often override trainees' misreading of the environment to speed them up. Residents don't always see the same cues, but if faculty surgeons are more explicit about what cues they are reading, residents will have more of an opportunity to learn situation awareness. You are more likely to become aware of cues that you anticipate.

The capacity to slow down when you should is not necessarily something that comes with expertise. A resident may have the capacity while a faculty member does not. Carol-anne defines expertise as a process of engaging in your environment and effortful reflection, rather than achieving a certain status or level. By deconstructing what is meant by judgement, it might be possible to evaluate and remediate when judgement is lacking. She is working with cognitive psychologist Glenn Regehr, qualitative analyst Lorelei Lingard, and surgeon Helen MacRae.

Carol-anne was born in Canada, but moved to Australia with her parents in Grade 11. She joined the staff at Toronto General Hospital as a hepatobiliary surgeon in September 2006. She finds the system in Toronto quite different from her experience as a trainee in Australia where the emphasis was almost exclusively clinical. She completed her MD at Melbourne University and surgery residency at the Austin Hospital in Melbourne. Her academic work began in Toronto during a fellowship in 2003. From 2004-2005 she did a Masters in Education with Richard Reznick; she began work on her PhD in 2006. She has three children, Jackson, 5, Connor, 3 and Kennedi, 1. Her husband Daryl is currently a full-time dad, enabling her to be at work at 7am when needed. Carol-anne and her colleagues Sean Cleary, Alice Wei and Steve Gallinger have created a group practice with a "one in four" call system, in which each does intensive clinical work for one week and research for three.

M.M.




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