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  Surgical outcomes may be attributed to reflection on previous positive and adverse experiences

  
  
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  Peer collaboration is an essential component for surgeon’s performance analysis

  
  
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  Critical observation, planning, and review cultivate judgment in the surgical setting

Postoperative complications have a profound impact in the surgeon’s learning process. Multiple variables influence the development of good judgment in surgical care. With little formal education in this area, surgeons rely upon previous experience from past complications as a historic “learning tool.” The appropriate critical review of surgical-related complications likely improves judgment in future patient care; such review should be systematic, critical, and objective, and allow for a shorter learning curve and for improved patient safety provided by the future generations of surgeons in training.

Any clinician would concede that reflection on technical or medical decision errors is not an area of comfortable focus in surgical training. There are, admittedly, few opportunities for immersion into this esoteric concept during the training period. There is, however, among the medical surgical community, an imperative for making sound medical decisions. The practice of surgery is regarded as one that requires consistent need for development of judgment.

Practitioners are frequently reminded of the requirements for knowledge reinforcement, updates, and refinement of current technique. The principle of sound judgment may seem somewhat nebulous, but in reality it is simply a constellation of responsible behaviors. Even with little formal education, there are compulsive means to assist in this endeavor, including collaboration, teamwork, and precedent. Medical professionals often refer to instinct. How is true clinical instinct manifested? Operative physicians claim to make decisions based on surgical instinct. However, what does this really mean and how can this be properly developed? It is recognized that behaviors are commonly a reaction of precedent to past occurrences, experience, and evidence-based data. Of these, anecdotal experience often does prevail, and is typically foremost when reviewing previous complications that have occurred.

In clinical behavior analysis, the medical decision process exists on multiple care levels.

Example of the Current Status in Orthopedic Surgery

Statistical data highlight the relevance of attention to this area of surgical care. More than 25,000 orthopedic surgeons exist in the United States at present. Currently, orthopedic surgery is 5th in ranking for the number of suits or claims filed with resultant money paid. Of these cases, 52% involve improper performance in surgery, 14% involve an error in diagnosis and indications, 8% involve failure to recognize complications, and 6% involve failure to supervise or monitor. There are 20% of other claims that involve smaller categories.¹ These data underscore the critical importance that judgment plays in determining prudent clinical care and avoiding medical malpractice allegations, which can hinder the care process.

A Surgeon’s Judgment: Where is it Applied?

The application of judgment in the surgical care of our patients occurs at three primary points of care.

These particular points of care occur at all levels of patient interaction, inclusive of preoperative, perioperative, and postoperative care. The process applies to well-known long-term patients, patients encountered in the urgent-care or emergency setting, patients who are covered while on-call after hours, and even patients from other practices or a colleague. Medical decisions may be more conspicuously evaluated in academic settings, where impressionable trainees are consistently watching and observing how care is handled to assimilate for their future behaviors. The presence of learners for any surgical practice highlights the importance of perspective in making appropriate judgment in surgical care.

Among practice in a teaching environment, a variety of different clinical roles may be assumed by a surgeon in any given clinical day.

When considering the critical nature of judgment development, it is important to assimilate these perspectives, thus creating a perspective of the significant impact of developing an analytic clinical awareness.

Indications and Education

Successful application of appropriate clinical indications is an underrated concept. Further, it is often difficult to properly apply indications in situations where patients have attempted to impose their own agenda that may not be reasonable. Key variables to address in terms of proper application of indications include the following:

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  Timing for surgery—especially relevant in the case of elective surgery

  
  
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  Nature of disease—variations in multidisciplinary care necessity

Multidisciplinary support may be necessary during optimization of comorbid medical conditions; as such, some aspects of care may be out of the hands of the surgeon. Long-term consideration must be made for ultimate patient disposition with specific disease processes in mind. Consideration of the environment with which they may rehabilitate or recover, as well as perspective of whether or not patients can anticipate being better after the procedure must be made. These thoughtful processes are of key importance to achieve success in making proper decisions.

The earliest opportunity that necessitates judgment by a clinician is at the point of intention to treat. No process may be more difficult to refine than the appreciation of treating the right patient with the correct procedure. Young surgeon trainees, while preparing for their respective certifications, cautiously consider indications and appropriateness in the context of evaluation for examinations. Often, in the aftermath of certification, such physicians may not as deliberately consider appropriate indication and timing for surgery. Regardless of training or practice phase, it is paramount that surgeons carefully consider appropriate indications at all points of their career.

Multiple external factors serve to influence indications for surgery as well. Patients may present for evaluation with a high degree of available self-education—information that may or may not be accurate. As a result, perceived misnomers easily occur and complicate the patient-physician relationship, particularly with the present desire for patient-shared decision making. Patients may present with information heavily influenced by commercial or industry-related products. Such information or products can virtually consume and convince patients that they should participate or “buy in” to a product rather than being treated for an appropriate condition. In such a situation, it is incumbent upon the surgeon or clinician to assume the role of educator in the patient care process, assuring that proper evidence-based information is presented, thus allowing for a complete shared decision making process.

Technical Ability and Self-Appraisal