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Slowing Down to Stay Out of Trouble in the Operating Room: Remaining Attentive in Automaticity

Moulton, Carol-anne MD, MEd, PhD; Regehr, Glenn PhD; Lingard, Lorelei PhD; Merritt, Catherine MSc; MacRae, Helen MD

doi: 10.1097/ACM.0b013e3181f073dd

Purpose Automaticity is integral to expert performance, but experts must be able to transition from an automatic mode into a more effortful state when required. In this study, the authors identified and characterized the manifestations of the phenomenon of “slowing down when you should” to stay out of trouble in operative practice.

Method The authors interviewed 28 surgeons (60-minute, semistructured format) from various specialties at four academic medical centers and observed 5 hepatopancreatobiliary surgeons in the operating room (29 cases, 147 hours) during 2007–2009. Using a grounded theory qualitative methodology, they conducted a thematic analysis of transcripts and field notes in an iterative manner. Data collection continued until saturation. They adopted a reflexive approach throughout.

Results Surgeons described and the authors observed four phenomenological manifestations of the transition to a more effortful state. In the most extreme manifestation, “stopping,” surgeons actually stopped the procedure, whereas in the most subtle manifestation, “fine-tuning,” surgeons were able to continue the procedure and focus on minor events simultaneously. A separate phenomenon of “drifting” represented surgeons' failure to transition out of the automatic mode when appropriate, resulting in surgical errors or near misses.

Conclusions The manifestations of the slowing down phenomenon represent acts of cognitive refocusing during the potentially more-critical moments of operative practice. Further, the authors challenge the conception of automaticity as effortless, arguing that automatic behavior can be attentive (fine-tuning) as well as inattentive (drifting).

Dr. Moulton is assistant professor, Department of Surgery, University of Toronto Faculty of Medicine, staff surgeon specializing in hepatobiliary and pancreatic surgical oncology, University Health Network, and scientist, Wilson Centre, University of Toronto, Toronto, Ontario, Canada.

Dr. Regehr is professor and associate director, Centre for Education Scholarship, Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada.

Dr. Lingard is professor and director, Centre for Education Research and Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.

Ms. Merritt is a PhD student, Department of Anthropology, University of Toronto, Toronto, Ontario, Canada.

Dr. MacRae is staff general surgeon, Mount Sinai Hospital, Toronto, and director, Surgical Skills Laboratory, University of Toronto Medical Faculty, Toronto, Ontario, Canada.

Correspondence should be addressed to Dr. Moulton, The Wilson Centre, Toronto General Hospital, 200 Elizabeth St., Eaton Sth 1-565, Toronto ON, M5G2C4, Canada; telephone: (416) 340-4800, ext. 8819; fax: (416) 340-3792; e-mail:

© 2010 Association of American Medical Colleges