Moulton, Carol-anne MD, MEd, PhD; Regehr, Glenn PhD; Lingard, Lorelei PhD; Merritt, Catherine MSc; MacRae, Helen MD
Automaticity is an important component of expert performance.1 As experts acquire experience and knowledge, they accumulate many automatic resources (such as pattern recognition) that provide them with the ability to “just know the right answer” or “just know what to do”—in other words, the ability to think and act in a predominantly intuitive manner. However, experts cannot stay in automatic mode all the time; they must transition into a more effortful state as the situation requires.2–4 Schön5 observed experts from various domains in the context of their daily practices, and he found that they engaged not only in “automatic” modes of thinking (which he termed “knowing-in-action”) but also in more “effortful” modes of thinking (or “reflection-in-action”). Thus, he highlighted the ability to think on one's feet during times of uncertainty as a central component in his model of expertise.
In previous work, we have argued that component of expert judgment in clinical practice is captured by the effective and appropriate transitioning from the automatic mode to the effortful mode when the situation requires it; we refer to this phenomenon as “slowing down when you should.”6 “Slowing down” represents the surgeon's cognitive refocusing or increased attention directed toward a particular task and describes the surgeon's experience during the critical moments of surgery. The term is not meant to describe the speed of the surgeon's hand movements, nor does it imply that the surgeon in any way slows down temporally, although both may occur. Rather, it describes the surgeon's experience of the transition from the routine to the effortful when additional cognitive resources are recruited to focus on the task at hand.
In an earlier qualitative study, we interviewed surgeons from a range of specialties about their experiences with this phenomenon and determined that slowing down moments may be situationally responsive or proactively planned.7 For example, if an expert surgeon is faced with unusual anatomy when removing the gall bladder, she slows down in response to the situation and focuses on the abnormality, rather than “plowing through” by remaining in automatic mode. Similarly, when an expert surgeon recognizes preoperatively that a colonic tumor might be invading the duodenum, he plans for a moment during the dissection in which he will slow down to approach the tumor using alternate anatomic planes. This transition to the more effortful state marks moments of increased attention during critical or unexpected events and is a means by which the surgeon “stays out of trouble” in the operating room. To be responsive to unexpected events, the surgeon must vigilantly monitor relevant environmental cues and appropriately interpret the cues as signals that he or she needs to transition into a more effortful state.
During that study, surgeons acknowledged the presence of slowing down moments in their operative practice that are marked at times by observable behaviors, like asking others in the room to stop a conversation or to turn the music off. They suggested that other operating team personnel (i.e., nursing staff, surgical trainees) may detect their slowing down moments and respond appropriately by cutting out distractions on their behalf. The surgeons also described various “telling signs,” such as whistling or humming, that marked this transition in other surgeons with whom they worked.
From the initial study, it appeared to us that surgeons' redirection or focusing of attention was an observable or, at least, a noticeable phenomenon that we could explore further using observational methods. From a cognitive perspective, transitioning from a relatively automatic mode to a more effortful mode requires an individual to recruit an increased level of cognitive resources or attention from a limited pool of resources.8 It is by engaging in monitoring activities that surgeons recognize the need for increased attention. The reallocation of attention that occurs with the slowing down moments may help mark these more-critical junctures during surgical procedures.
The purpose of this study was to identify and describe the manifestations of the slowing down phenomenon in surgical operative practice by supplementing surgeons' descriptions of these events with observations of the phenomenon in intraoperative contexts. By identifying the transitions in practice, we may be able to help individual surgeons pinpoint potentially critical moments that require more effort and lead them to a greater understanding of why they feel increasingly distracted or annoyed by concurrent activities.
We designed this study using grounded theory, a qualitative methodology intended to explore a social phenomenon for the purpose of generating a descriptive or explanatory theory that is “grounded in” (i.e., derived from) naturalistic data.9–11 In this study, which was part of a larger study exploring the role of slowing down when you should in the area of intraoperative surgical judgment, we explored one theme: the manifestations of the slowing down phenomenon in the operating room. We have described elsewhere the methodology of the larger study and two other themes—the initiators and influences of the phenomenon and the control dynamics associated with the display of the phenomenon in the educational context of the operating room.7,12 In this article, we will describe the pertinent methodological points as they relate to the exploration of this theme.
Four tertiary care academic medical centers (Toronto General Hospital, Toronto Western Hospital, Princess Margaret Hospital, and Mount Sinai Hospital) affiliated with the University of Toronto provided the setting for this study, which took place in two phases across a 16-month period (phase 1: November 2007 to April 2008; phase 2: May 2008 to February 2009). We obtained approval from the institutional review boards at the involved hospitals.
Phase 1 of this study involved 60-minute, semistructured interviews with 28 surgeons who were selected on the basis of their reputations for having excellent surgical judgment. They represented a variety of specialties (general, n = 9; neurosurgery, n = 4; orthopedics, n = 3; cardiac, n = 3; vascular, n = 3; head and neck, n = 2; plastics, n = 2; thoracics, n = 1; trauma, n = 1). The principal investigator for this study (C.A.M.), who is a hepatopancreatobiliary (HPB) surgeon, and a research assistant (C.M.) with a master's degree in anthropology jointly interviewed all of the surgeons about their perceptions of and experiences with the “slowing down” phenomenon.7 Consistent with the iterative design of grounded theory, they conducted further interviews with 8 surgeons from the original group of 28 to probe an emergent theme: These participants had denied quite vehemently in their original interview that they were ever in the automatic mode when operating. The 8 surgeons were further questioned on their perceptions of “automaticity” and their ideas about their “routine” mode of functioning in their operative experience. Each interview in phase 1 was audio-recorded and transcribed.
The manifestations of the slowing down phenomenon that emerged as dominant themes from phase 1 were explored iteratively in the second phase of the study. In phase 2, the lead investigator and research assistant conducted observations in the operating rooms of five HPB surgeons over a 10-month period (29 cases, 147 hours) to expand, confirm, and refine the preliminary framework developed from phase 1.7,12 The two researchers observed the surgeons together until the research assistant was trained in observation methods. They then observed the surgeons independently but occasionally worked together to explore similarities and differences in their observations.
The phase 2 surgeons were purposefully selected13 from the same specialty as the principal investigator to enhance her ability to detect subtle nuances of the slowing down phenomenon and to understand the intricate technical and cognitive operative details.10,14 During and after surgery, the observing researcher discussed with the operating surgeon his or her interpretations of operative events and asked the surgeon to comment specifically on the researcher's interpretations of the slowing down moments. All pre- and postoperative interviews were audiotaped, and many of length were transcribed.
In all cases, it was the staff surgeon who was observed performing the procedure or maintaining either “direct” or “overall control” of the procedure through the hands of the trainee.12 The HPB cases were advanced cases that required the staff surgeon to be an integral component of the procedure. The researchers did not observe or interview the trainees as this study explored the phenomenon of slowing down in the context of expert performance.
Surgeons involved in phase 2 were not participants in phase 1. This was an intentional decision: We did not want the HPB surgeons being observed to have previously reflected on or explicitly considered the slowing down phenomenon.
The lead investigator and research assistant conducted thematic analysis of the transcripts and field notes from phase 2. They compared the preliminary categories they had identified and discussed discrepant categories; periodically and when discrepancies persisted, they brought the relevant excerpts from the transcripts or field notes to the larger research team.
The larger research team consisted of the principal investigator, the research assistant, a cognitive psychologist (G.R.), a surgeon (H.M.), and a qualitative researcher (L.L.). We met regularly to elaborate and refine the evolving framework as data collection progressed.10 Also, a key informant (an HPB surgeon who became interested in the phenomenon and was able to be reflective about the emergent ideas and themes) provided us with opportunities for additional discussions and interviews that helped us refine the various categories.15
Data collection continued until further interviews and observations ceased to inform our emergent thematic framework.16 We ensured confirmability by maintaining an audit trail of all analytical memos, minutes of the meetings, and revisions to the coding structure. We applied the final coding structure to the complete data set using NVivo 7 software (QSR International Pty Ltd., Cambridge, Massachusetts) to facilitate cross-referencing.17 We adopted a reflexive approach at all stages of the research process.
As surgeons were observed in the operating room transitioning from a routine mode to a more effortful mode, the range of phenomenological manifestations of slowing down expressed during the phase 1 interviews became apparent, and we were able to elaborate on and refine them. We detail below the various transitions that surgeons described and we observed, from the most extreme manifestation of “stopping” to the most subtle of “fine-tuning.”
The most extreme manifestation of slowing down occurred when surgeons actually stopped the progression of the operation (refer to the example from a reflective field note in Table 1). Often, surgeons described stopping in relation to critical intraoperative moments when they knew they required more information. Researchers observed this in the operating room as a stop in the procedure while the surgeon sought further information: The surgeon might ask a colleague for assistance, look up reports from the patient's file, or review imaging. Surgeons interviewed in both phases frequently used words such as “regroup” and “reassess” to describe these situations, reflecting the uncertainty that was so often linked to this critical transition.
Stops were sometimes prearranged for the purpose of setting up the surgeon's environment to prepare for these more-critical proactively planned slowing down moments. Surgeons would stop the procedure and ensure all necessary team members were ready and had the required resources available. Some surgeons described engaging in a mental rehearsal to focus themselves and their team on the task at hand. Surgeons appreciated the critical nature of these moments; they understood that once the first step was initiated, the subsequent steps would necessarily follow in what might be a time-pressured situation or a difficult-to-control cascade. Many study participants described stopping or were observed stopping in this study, including orthopedic surgeons getting ready to divide the pelvis, vascular surgeons preparing to open an aneurysm, and HPB surgeons preparing to clamp the portal vein.
Stopping, whether it occurred as a function of an emergent issue or was proactively planned, was clearly a strategy that provided cognitive space for surgeons to consider the situation or gather new information.
Sometimes, the surgeon, on encountering a slowing down moment, became irritated or distracted by various stimuli and told others in the operating room to remove them so that he or she could focus on the task at hand. Removing distractions made available the additional cognitive resources that the surgeon required to transition into the effortful state and focus on the critical event. One surgeon described this manifestation as he discussed his slowing down moments:
I think I notice the noise level. When things are going smoothly, you hardly notice it and when things get a little rough in there, you notice it much more.… [T]he anesthetist doesn't realize what's going on and they're still nattering away about what the Raptors did last night, so I usually have to just tell them, hold it a minute here until I see what we're doing with this. - —Surgeon A05, phase 1 interview
In phase 2, surgeons were observed removing distractions during the potentially critical slowing down moments. The operative team, however, did not always recognize the need for this, as illustrated by the example in Table 1 of a resident's continuing her “chatter.” Many members of the team did notice, however, and took steps to remove distractions themselves, without the surgeon's prompting. Nurses and surgical trainees, at such moments, were observed turning music down or off, turning away visitors to the operating room, and requesting that conversations be taken outside. Even when scrubbed, surgeons and staff could relay the same messages with eye contact and head motioning. Many surgeons recognized that experienced members of their surgical team eliminate distractions on their behalf. One phase 1 surgeon (A04) proclaimed, “Good nurses get it and residents may not.” During a phase 2 observational session, a clinical fellow was overheard telling a junior resident after an operative case that “you take cues from the surgeon when to talk and not talk,” demonstrating that the reverence or respect for these moments is not necessarily an intuitive skill but rather one residents may acquire over time with training.
Focusing more intently
A somewhat more subtle manifestation of the slowing down phenomenon in the operating room was demonstrated when the surgeon allowed external distractions to continue but ceased to participate in such activities and focused his or her attention on the procedure exclusively. During the observational sessions, surgeons who were focusing more intently did not appear to be distracted by conversations and noise around them as long as it was not directed at them. They simply appeared to be “dropping out” of conversations or teaching interactions as they focused on the operative field (Table 1).
One phase 1 surgeon (B02) described the transition this way: “If you ask me to talk about my vacation or where I go take my car for repair, of course I can't anymore. It becomes distracting to what am I doing.” Many surgeons recognized that the level of attention required during the critical slowing down moments made them unable to split their attention with another task (i.e., teaching or talking). One surgeon (A10) explained in a phase 1 interview, “If it is a real critical part I'll be the one that does that part and chances are there will be less teaching at that point in time, less talking at that point in time.”
Some surgeons described particular “telling signs,” either their own or their colleagues', which indicate to the outside observer that the surgeon is in the midst of a slowing down moment. One phase 1 surgeon (A14) shared his own sign: “And you'd also see me, maybe I'm starting to sweat a little bit, I'm just not as happy as I was, I'm not enjoying it as much as I was.” Another described a colleague's:
I get to work with everybody so I've seen everybody in that situation…. Dr. [name withheld] has an interesting one … he'll start singing or humming “La vie en rose.” It's, like, he sings a particular song, he hums a song and it's always the same one, when he's stressed. - —Surgeon A13, phase 1 interview
During phase 1 interviews, surgeons offered examples of what appeared to be very minor transitions from the routine to the effortful state that would occur numerous times throughout any given procedure. These transitions appeared to be responsive, but on a much smaller scale than those described above, and to fit best as a separate category of “fine-tuning.” As one surgeon explained,
I mean there are junction points during an operation during which you have to make a judgment, you have to make a decision but more than that there are multiple small nodal points where you have to go this way or that way, probably thousands. - —Surgeon B04, phase 1 interview
Surgeons described engaging in this fine-tuning activity on a moment-to-moment basis, responding to emergent cues (e.g., readjusting angles, approaches, technique) to stay out of trouble. According to one surgeon,
Even performing a relatively routine part of the Whipple, like dissecting out, or dividing the small bowel mesentery, each time we tie the end that is staying in, I pay a little more attention. Others would not necessarily notice this. - —Surgeon OR05, phase 2 interview
During the observational sessions, fine-tuning appeared to manifest as momentary increases in attention or focus that occurred throughout the procedure. The surgeon appeared to be responding to or focusing on a technical issue (e.g., finding the correct dissection plane, tying off an important vessel) to safely deal with the issue at hand. During these minor transitions, surgeons were able to continue with other activities (e.g., talking, teaching, listening to music) with few, if any, interruptions (Table 1).
The fine-tuning events were not obvious transitions from the routine mode to the effortful mode and went largely unnoticed by others in the operating room. In fact, many fine-tuning transitions were so subtle that they were not noticed by the research assistant (who is not a surgeon). The lead investigator, an HPB surgeon with knowledge of the procedures, detected many fine-tuning events, though likely not all of them. It was in discussions with the key informant that this category was refined in conjunction with rereading the transcripts from the interviews in phase 1 and ongoing observations from the operating room in phase 2.
Fine-tuning appeared to represent the interplay between the finer aspects of the cognitive and technical components of surgery and, therefore, to require detailed, content-specific procedural knowledge of the surgery to be detected by an observer. The purpose of engaging in this fine-tuning activity appeared to be to keep the operation on course and avoid injury (e.g., putting a hole in a vessel, compromising a tumor margin). By responding appropriately to emergent cues through fine-tuning transitions, surgeons avoided “incidents” that would have required more effort and could have jeopardized the safety of the patient.
Failure to slow down: The state of “drifting”
During the phase 1 interviews, many surgeons provided examples of times when they may drift dangerously into an inattentive state while operating. In fact, when surgeons considered the word automatic, drifting seemed to be what they were thinking about, which may explain why a subset of surgeons vehemently objected to ever being in the automatic mode. Surgeons recognized drifting as a consequence of complacency during the more routine, mundane, or “boring” parts of the procedure. Referring to a recent mishap in the operating room, one surgeon explained,
It's the routine cases … it's like the … bile duct injuries always happened in easy gall bladders, right? That's what happened here. It was an easy case. We were chatting and obviously not being as diligent as we should have been. - —Surgeon B03, phase 1 interview
This was a common admission: When surgeons allow themselves to drift, they fail to engage in the essential monitoring activities that allow them to detect the cues that will initiate a slowing down event. Drifting was observed in the operating room, as the lead investigator noted:
The senior surgeon was removing the head of a pancreas on a patient with an aberrant artery. He carefully dissected out this artery as it was crucial to the procedure that it be preserved. Having completed this step, he continued to the usual next step, dividing the small bowel mesentery. While the surgeon assisted the fellow in this more mundane and routine part of the procedure, the surgeon and trainee engaged in extraneous conversation. Returning to the porta hepatis, the surgeon placed the right angle around the bile duct, forgetting, for that moment, the aberrant artery that had been delicately dissected out 30 minutes before. Unknowingly the artery was tied off with the bile duct. In the postoperative interview, the surgeon explained that it was normally such a routine part of the procedure and admitted to being distracted by conversation. He appeared to have drifted in a mode of “just tying off the bile duct,” forgetting the variation in this patient. - —Surgeon OR05, phase 2 field notes
Many surgeons described the state of drifting in relation to an adverse event that occurred and that appeared to be the negative consequence of inadequate fine-tuning or monitoring. The surgeon's failure to monitor appropriately led to a lack of fine-tuning, which caused a mishap to occur.
We have proposed the phenomenon of “slowing down when you should” as an important marker for the display of intraoperative surgical judgment.6,7 As noted above, it is not the surgeons' hands or movements that necessarily become slower but rather the focus of their attention that changes. While the surgeons in this study sometimes described a simultaneous decision to actively slow their movements down or make them more deliberate, their doing so seemed to be a consequence of their desire to regain or retain control during these critical moments. This important distinction is consistent with the widely accepted “capacity model” of attention, which suggests that humans work within a limited capacity of attention.8 When the threshold is reached, an individual cannot give further attention to a stimulus without taking attention away from other stimuli.
Using this model, we can begin to interpret the various manifestations of the slowing down phenomenon seen in our study as representative of behaviors found along a spectrum of investment in cognitive effort. As the surgeon requires more cognitive resources to carry out the physical and mental processes involved with a particular surgical task, the surgeon takes more attention away from other activities. As the surgeon transitions from a routine state to a more effortful state, various levels of recruitment are necessary to meet the demands of the task, which manifest in different ways. In general, the larger the amount of cognitive resource recruited for the task, the more dramatic the manifestation (i.e., stopping) that accompanies it. This may not always be the case in situations where a life-threatening event forces a surgeon to continue operating. The surgeon might like to stop and regroup, but time does not allow it; therefore, the transition might be observed as a less intense manifestation of removing distractions or focusing more intently.
This overlay of manifestations onto a framework of cognitive recruitment may not be a perfect match, but it is nonetheless useful for understanding the various manifestations that accompany the slowing down phenomenon. Although it is useful to conceptualize the manifestations as occurring along a spectrum, we do not intend to imply that recruitment in cognitive activity occurs through stages and proceeds from one level to the next in a linear fashion. Rather, it is more appropriate to consider the various manifestations as fluctuations in discrete amounts of cognitive investment. A surgeon engaging in fine-tuning activities, for example, might recognize an abnormality and suddenly stop the procedure, traversing no other “levels” along the way.
Choosing to observe HPB surgeons was an intentional sampling strategy based on the fact that the principal investigator (C.A.M.) is an HPB surgeon. She would be able to detect subtle nuances of the slowing down phenomenon and also have the ability to understand and make informed attributions for what was going on surgically—weaving together a story of slowing down events and their surgical relevance. We believe this strategy enabled us to expand and refine the manifestations of this phenomenon in a way that otherwise would have been impossible.
The subtleties of the phenomenon, however, pose significant implications for future research. It would be difficult, if not impossible, to place “naïve” observers in the operating room and train them enough to detect the more subtle manifestations of fine-tuning and focusing more intently. Although the research assistant (C.M.), with training, was able to detect the range of manifestations (including some instances of these more subtle manifestations), she also missed many instances as well as the surgical details that were essential for adding meaning to the story. It is unclear whether even a trained surgeon in one specialty could detect the subtleties of a surgeon in another specialty. Further, a potential limitation of having a surgeon observe in his or her own environment is the issue of familiarity—of not noticing events and practices that might otherwise inform the phenomenon. The principal investigator broadened her perspective by engaging in the process of reflexivity—examining and exploring her own assumptions and presuppositions of what she might find—and involving a second observer (the research assistant) outside the field of surgery.
Importantly, the subtleties of the slowing down phenomenon also have implications for both the smooth functioning of the operating room and the training of novice staff and residents. That is, surgeons recognized that not all members of their team detected their slowing down moments. Knowledge of the cognitive fluctuations in members of the surgical team, particularly during the slowing down moments, might provide sensitivity to this dynamic nature of the surgical environment and improve the performance of the surgical and operating room team.18 Also, it is probable that trainees (medical or nursing) reach their “attentional threshold”8 before surgeons do, so extraneous conversations, music, or noise may be distracting for the trainee but not the surgeon. If trainees lack the “right” or ability to remove distractions, they may be unable to dual-task effectively, and their performance may suffer.19
Further, if trainees do not detect the staff surgeon's more subtle transitions or slowing down moments—manifested as fine-tuning or focusing more intently—they are less likely to appreciate the subtle nuances that require cognitive effort and minor readjustments in technique. This has obvious implications for teaching and training and may be one reason why some trainees seem to plow through procedures, failing to slow down appropriately.7 It is not always obvious to the trainee why the staff surgeon slows down because the trainee may not appreciate fully the cues that have alerted the surgeon. Similarly, the trainee may not appreciate the surgeon's fine-tuning maneuvering and therefore may miss the surgeon's focus directed at simply “staying out of trouble”—a key component of surgical judgment.
It is important to note that some surgeons, while appreciating the phenomenon of the transition, felt less personal resonance with the construct of automatic activity. As Surgeon OR01 commented during a phase 2 interview, “I don't think we're automatic. I don't think we can be … but I guess there are levels, right?” Consistent with this position, during the observational sessions, the principal investigator began to notice that the surgeons being studied rarely looked as if they were in a truly effortless mode, even during routine aspects of the procedures. Reading the expertise literature, though, one might develop an image of surgeons' movements in the operating room as unconscious, quick, fluid, and effortless, becoming effortful when the occasional situation requires it.1,20 This image of expert automaticity, as a sense of detachment from the activity, was not regularly demonstrated in this study; to the extent that it was, it manifested as sufficiently different from the usual surgical practice of fine-tuning that it was recognized as the separate phenomenon of drifting. More often, it appeared that even though surgeons' hand movements demonstrated an economy of motion—lacking the clumsiness of novices, for instance—some parts of their cognitive processes were constantly engaged in and attentive to their environment. Surgeons described this background monitoring activity as a “heightened sense of surveillance.” We believe that it is from this heightened baseline awareness that surgeons momentarily dip into their cognitive resource pools and slow down to make minor adjustments and technical maneuvers to stay on course—the subtle manifestation of the slowing down phenomenon we refer to as “fine-tuning.”
By contrast to this state of monitoring and heightened surveillance, surgeons in this study described the state of drifting as a negative by-product of automaticity, a state of inattention that could lead to error. This view might explain why they were reluctant to consider automaticity as their baseline level of functioning. The “cost of automaticity” is discussed in the broader attention literature concerning procedures that are highly routinized but, at the same time, require close attention.21,22 Errors in such systems, like those described by surgeons in this study, occur because routinization leads to automatic behaviors that are not accompanied by close attention.21 Often, the only evidence of drifting in these situations is when errors occur. Drifting has been suggested by some to be beyond the control of the individual working in such routine or automatic conditions. Toft and Gooderham22 refer to drifting as “involuntary automaticity” and go so far as to suggest it as a potential legal defense against allegations of clinical negligence in situations where organizations have not taken measures to counteract or consider the influence of automaticity on their workers' performance.
On the basis of what we observed in the operating room, we propose that being in an automatic mode is not an “all or none” phenomenon; rather, it can be further characterized by how much attention is being reinvested into monitoring activities during the case.
Automaticity might best be divided into two states, described as “attentive automaticity” and “inattentive automaticity.” Working in a dynamic environment, surgeons are required to maintain some degree of situational awareness, with the ability to redirect attention to the important cues when necessary. This requires cognitive effort to be directed toward metacognitive monitoring to “remain aware of the whole situation, to monitor events as they occur, to reflect on alternative possibilities should a decision need to be made,”23 and to monitor processes that are happening automatically.23 When this monitoring activity fails, drifting occurs.
The important role of metacognitive monitoring for health care professionals has been the recent focus of research programs in medical education24–27 that have expanded researchers' views of expertise beyond the “expertise as automaticity” model. It is possible to consider that a true expert is someone who reinvests freed-up cognitive resources (a benefit of being automatic) into the moment-by-moment monitoring of his or her clinical activities—a process that requires purposeful attention and effort. The “cost” of automaticity and the potential for drifting into an inattentive automatic state have important implications for patient safety and may help educators instill in the next generation of health care professionals the importance of remaining purposefully attentive, of reinvesting their cognitive resources back into the case to function as a metacognitive self-monitoring and self-corrective feedback tool.24,28
This study was funded by the Physician Services, Inc.
This study was approved by the University Health Network research ethics board and the University of Toronto office of research ethics.