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Surgeon Perception of Risk and Benefit in the Decision to Operate

Sacks, Greg D. MD, MPH; Dawes, Aaron J. MD; Ettner, Susan L. PhD; Brook, Robert H. MD, ScD; Fox, Craig R. PhD; Maggard-Gibbons, Melinda MD, MSHS; Ko, Clifford Y. MD, MS, MSHS; Russell, Marcia M. MD

doi: 10.1097/SLA.0000000000001784
Features

Objective: To determine how surgeons’ perceptions of treatment risks and benefits influence their decisions to operate.

Background: Little is known about what makes one surgeon choose to operate on a patient and another chooses not to operate.

Methods: Using an online study, we presented a national sample of surgeons (N = 767) with four detailed clinical vignettes (mesenteric ischemia, gastrointestinal bleed, bowel obstruction, appendicitis) where the best treatment option was uncertain and asked them to: (1) judge the risks (probability of serious complications) and benefits (probability of recovery) for operative and nonoperative management and (2) decide whether or not they would recommend an operation.

Results: Across all clinical vignettes, surgeons varied markedly in both their assessments of the risks and benefits of operative and nonoperative management (narrowest range 4%–100% for all four predictions across vignettes) and in their decisions to operate (49%–85%). Surgeons were less likely to operate as their perceptions of operative risk increased [absolute difference (AD) = –29.6% from 1.0 standard deviation below to 1.0 standard deviation above mean (95% confidence interval, CI: –31.6, –23.8)] and their perceptions of nonoperative benefit increased [AD = –32.6% (95% CI: –32.8,–-28.9)]. Surgeons were more likely to operate as their perceptions of operative benefit increased [AD = 18.7% (95% CI: 12.6, 21.5)] and their perceptions of nonoperative risk increased [AD = 32.7% (95% CI: 28.7, 34.0)]. Differences in risk/benefit perceptions explained 39% of the observed variation in decisions to operate across the four vignettes.

Conclusions: Given the same clinical scenarios, surgeons’ perceptions of treatment risks and benefits vary and are highly predictive of their decisions to operate.

*Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, CA

VA Greater Los Angeles Healthcare System, Los Angeles, CA

Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA

§Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA

||RAND Corporation, Los Angeles, CA

Anderson School of Management, University of California, Los Angeles, CA

#Department of Psychology, College of Letters and Sciences, University of California, Los Angeles, CA.

Reprints: Greg D. Sacks, MD, MPH, Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 72–227 CHS, Los Angeles, CA 90095; E-mail: gsacks@mednet.ucla.edu.

Disclosure: Two of the authors (G. D. S and A. J .D.) received support from the Robert Wood Johnson/Veterans Affairs Clinical Scholars program.

G. D. S. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. He conducted and is responsible for the data analysis.

The authors declare no conflicts of interest.

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