Surgeons, as health care professionals, are granted the privilege of self-regulation with the responsibility of identifying and countering threats to patient safety and improving the quality of the care they provide.1,2 Thus, individual surgeons are expected to monitor their own performance and to continually assess limits of their own competence (e.g., by asking themselves, “Am I skilled enough to do this procedure? Am I out of my depth? Should I call for help?”).3–5 When surgeons are presented with novel, uncertain, and challenging situations, their ability to recognize and accept the limits of their competence is paramount to patient safety as well as public trust.
For surgeons, a first step toward regulating personal performance is to understand the processes behind their decisions in the operating room (OR). To date, the majority of research in surgical judgment and decision making has been rooted in the principles of cognitive psychology, including situation awareness,6,7 cognitive heuristics and biases,8,9 and naturalistic decision making.10–12 As an example, in the naturalistic decision-making paradigm—which explores surgical decision making in the realistic setting of the OR rather than the standardized environment of a laboratory—decisions are classified as intuitive/recognition-primed, rule-based, analytical, or creative.10 Similarly, cognitive mechanisms, such as loss of situation awareness or cognitive shortcuts, have been used to account for errors in decision making.9,13,14 Although this work has led to important insights into how decisions are made in complex environments, its focus on the cognitive aspects of decision making has inadequately addressed other important facets of practice—specifically, the emotive and affective components.15 Furthermore, surgeons do not work in isolation but, rather, are embedded in a rich sociocultural milieu; consequently, they experience particular emotions or pressures induced by this culture, such as the need to manage their image or maintain hierarchical structures.16
The impact of internal emotions and external environmental pressures on decision making has been explored in airline pilots. Paletz et al17 identified the presence of social psychological pressures such as informational social influence, normalization of deviance, and impression management. As an example, pilots described a reluctance to cancel a flight because of bad weather to avoid social disapproval and passenger disappointment. Similarly, the ability of surgeons to self-regulate and self-monitor complex surgical decision-making processes relies on their understanding of their own external and internal environments.3,18
Recognizing that there are contextual factors that influence intraoperative performance in a complex sociocultural surgical environment, we explored surgeons’ perceptions of the factors that influence their intraoperative decision making, including the potential outcomes of their decisions. In so doing, our goal was to bring researchers and surgeons a step closer toward understanding the psychosocial factors that underlie surgical decision making, and to challenge the community to consider the individual, systems-level, and cultural changes necessary to improve patient safety in the OR and to lead to more effective self-regulation of the surgical profession.
This qualitative study used constructivist grounded-theory methodology to generate a theory that is “grounded in” (i.e., derived from) naturalistic data and is co-constructed between researcher and participant.19–21 This study took place at four tertiary care academic hospitals associated with the University of Toronto Faculty of Medicine. Purposive sampling22 was employed to capture participants across specialty, experience level, and gender. Institutional ethics review board approval was received from the University Health Network, Mount Sinai Hospital, and the University of Toronto.
The principal investigator (C.M., a surgeon and qualitative researcher) and a research assistant (A.L.) conducted semistructured 60-minute interviews with 39 academic surgeons in various specialties (general, n = 18; neurosurgery, n = 4; orthopedic, n = 4; cardiac, n = 3; vascular, n = 3; thoracic, n = 2; otolaryngology, n = 2; plastics, n = 2; trauma, n = 1).
An interview template (List 1) was used to guide both the researchers and participating surgeons in their exploration; this template was modified during the course of the study to help refine and expand on emergent themes consistent with the iterative design of this study. Surgeons were asked to describe a memorable personal complication or error and to discuss the situational and contextual factors surrounding the event. They were also asked to broadly describe the factors that influence their intraoperative decision making which, in their opinion, might lead to complications or errors and/or may make their decisions more pressured or difficult. As factors emerged from the interviews, they were proactively explored in future interviews, consistent with the iterative design of qualitative studies. Interviews were audio-taped, transcribed, and entered into NVivo qualitative data analysis software, version 9 (QSR International Pty Ltd., Doncaster, Victoria, Australia) to facilitate analysis and cross-referencing.23
A thematic analysis of the transcripts was conducted based on a constructivist grounded-theory approach.20,24 Preliminary themes were identified during data collection and iteratively elaborated and refined as data collection progressed. Coding was performed by two researchers (C.M., A.L.) who read the entire data set. A constant comparative approach to data analysis was employed to allow new instances from subsequent data collection to be compared with existing themes.25 The themes referring to influences on decision making were labeled factors. This coding structure and the emergent theoretical framework were discussed, refined, and confirmed by other members of the research team: a cognitive psychologist (G.R.), two surgeons (M.L.M., S.G.), and another research assistant (S.L.). Sampling continued until saturation of the key emergent themes (the point in qualitative research where ongoing data collection fails to change or add to the existing theoretical framework) was achieved.
After emergent factors arose in an inductive manner, we chose to overlay a preexisting theoretical framework from the professionalism literature26 (described in the Results) because it appeared to resonate well with our findings. In this way, the analysis was both inductive, because factors were generated from the data, and deductive, because the data were meaningfully interpretable when understood in the context of a previously published conceptual framework of professionalism.
The 39 academic surgeons readily described multiple factors involved in their surgical decision making, uniformly acknowledging that balancing multiple competing priorities is an explicit act in which they engage on a daily basis. They considered themselves to be wearing many different “hats” with competing priorities that require negotiation. They felt commitment first and foremost to patient care, repeatedly commenting that “patients always come first.” However, they also felt commitments to other responsibilities, such as teaching, administrative duties, research, family members, their careers, other patients, and colleagues. These commitments were conflicting at times and required surgeons to prioritize and balance risks and benefits in their decision making.
Although individual surgeons did not group the factors they mentioned in any particular way, there appeared to be differences in how they described, rationalized, and experienced them. The different properties of these factors appeared to us to align well with distinctions previously made by Ginsburg et al26 when proposing a framework to consider factors involved with issues of professionalism. Below, we elaborate on and relate our findings to each of that framework’s three categories—avowed, unavowed, and disavowed. In Table 1, we list factors described by multiple participant surgeons and exemplars of quotations, but the table is not meant to be a comprehensive list of the factors that may influence surgical decision making.
Factors considered to fit the avowed category were those aligned with the ideals of the profession (e.g., “First, do no harm”) and discussed as part of surgeons’ clinical reasoning: “It was safer to convert to an open procedure at that stage” or “The procedure was abandoned because of dense fibrous scarring.” It is unlikely that surgeons’ use of these factors in their decision-making processes would be challenged: These are considered to be “in the best interest of the patient” and are widely expected and accepted in the profession. As one surgeon described, “With his [the patient’s] cardiac history, I decided a quick operation is a good operation, and didn’t let the resident do much” (Interview 22, C05). In this instance, the surgeon decided to forego teaching responsibilities to choose what was best for the patient because the risk of delaying the procedure appeared too great.
There was a widely held declaration among the surgeons interviewed that despite the competing priorities and interests experienced by surgeons at any given time, “the patient on the table is the only one that matters” (Interview 18, C02).
Factors considered to fit the unavowed category were those that were aligned with unacknowledged or undeclared principles but were considered somewhat necessary for surgeons to manage their multiple commitments and priorities. These included such decisions as “rushing to finish this case on time to avoid cancellation of the next case” or “letting the trainees do the case for purposes of teaching.” In other words, unavowed factors were not directly attributed to benefits for the patient on the operating table but were considered reasonable and even necessary “for the greater good.” Participating surgeons considered these factors to be acceptable and inherent risks of having an academic surgical practice. Such factors would be discussed among surgeons without too much fear of condemnation and perhaps even with an expectation of acceptance, but it is unlikely that these factors would be declared to individual patients or their families.
For example, one factor mentioned by most participants was the pressure of time:
I think the pressure of the clock is distracting and you hurry things along.… We know that it is a wrong thing to operate by the clock but we’re put in a position where we’re in some ways forced to do that. (Interview 1, A01)
Another factor surgeons brought up, in discussions about “calling for help” during an operation, was consideration for colleagues. One surgeon described a complication that occurred at night and attributed it to a failure to call a colleague in to help with the complicated procedure:
It’s mostly just not having to inconvenience someone. You feel bad. They have a list the next day. They’re not on call. Our life is busy enough as it is. (Interview 20, C04)
The factors considered to fit the disavowed category (e.g., monetary motivations, concern for personal image and reputation) were those that would benefit the surgeon but not necessarily the patient, would be actively denied by the profession, and would be discouraged as being inconsistent with the call to “first, do no harm.” Publicly, surgeons would explicitly deny, disclaim, or denounce being motivated by these factors. In our study, surgeons described these factors more freely, particularly in the context of hypothetical scenarios or anonymous peers. One surgeon described the influence of monetary incentives as follows:
If you’re in a fee-for-service world and it’s a marginal call, maybe needs an operation, maybe doesn’t…. It is inconceivable to me that there is not some financial element that goes into decision making in surgery. (Interview 11, A17)
Surgeons also described pressures to fill their operating lists with cases for fear of having their OR time decreased in an era of limited resources. One surgeon noted:
I mean in the back of your mind, you get this many OR days, if they’re constantly saying, well she is giving up her OR days because she can’t fill her list, does she need that much OR time? (Interview 19, C03)
The pressure to fill the operating list was described by another surgeon as a “pressure to appear busy.” This was tightly linked with identity as a “successful” surgeon, providing reasons in addition to fear of losing OR time for filling the operating list with an adequate number of cases.
The surgeon’s ego or overconfidence was another disavowed factor:
There are ones like, well do I really need this help, do I want to seem like a loser, am I going to call someone? (Interview 25, C10)
I was called a pussy willow that I wouldn’t operate on these things. (Interview 14, B05)
Fear for reputation and issues related to hierarchy also seemed to influence some surgeons in their decision making.
Constructing stories: Rationalization of factors used in decision making
Of note, when detailing situations in which two or more decision options appeared to have similar risk–benefit profiles, some surgeons described their decision making as guided by projecting ahead to the quality assurance rounds to consider which option might be more acceptable to their colleagues when scrutinized in a more public forum. However, some surgeons described anonymous peers in these situations as succumbing to unavowed or even disavowed factors if it would be possible to construct a plausible story using avowed factors to rationalize the decision. One surgeon explained:
One of my teachers used to say there’s nothing in this world more dangerous than a surgeon who has got a gap in their OR schedule because he’ll make bad decisions and those decisions may be based on greed. In terms of softening indications for surgery, people sometimes put an academic guise on it. (Interview 17, C01)
Recognizing that there is difficulty in admitting that unavowed and disavowed factors influence decision making, another surgeon described how, “in the past,” he had let certain factors affect his intraoperative decisions but probably had not acknowledged it to himself at the time:
I probably have rationalized…. I bet there was a case somewhere where I had to get to the ball game or go to dinner or something like that where I made a decision based on that. Although that would be something I would never admit to myself at the time. But it happened. (Interview 29, D06)
Tension created by discussion of unavowed and disavowed factors
When we asked surgeons to identify and discuss the causes of personal errors, near-misses, or adverse events, they had little difficulty describing the avowed and unavowed factors that they felt played contributory roles. They appeared less comfortable, though still willing, to describe the disavowed factors highlighted above. However, asking them to do this in the reverse order—to first reflect on individual factors and then describe a time when those factors led to patient harm—appeared to generate tension.
One surgeon’s comments illustrated this tension well. During the course of the interview, the surgeon described factors that had contributed to a divided ureter in a laparoscopic procedure. The surgeon had wanted to be a “good teacher,” and so she had allowed the resident to continue operating even when the surgeon became uncomfortable and lost anatomical landmarks herself. Later in the interview (about 40 minutes later), she was asked how she balanced her teaching responsibilities with patient safety. She said she accepted little imperfections from trainees, but she “wouldn’t let someone divide a tumor to just let them learn about it” (i.e., risk harm to the patient). When she was challenged regarding the difference between dividing a tumor versus a ureter, it appeared to the interviewers that the surgeon was uncomfortable and experienced an internal struggle as she recognized the paradox in what she had said:
No, what I mean by letting them divide the ureter, I wouldn’t let them do that…. The problem was in that moment everything happened so fast. If I thought there was a chance that she [the resident] might injure the ureter…. I guess I did kind of think it but I thought that by coaching her I could avoid it. (Interview 20, C04)
When we asked surgeons to discuss competing pressures and factors a priori, they did so willingly, but when we asked them if these ever led to patient harm, they appeared unwilling or unable to acknowledge these as sources of harm to patients. One surgeon described his experience with time pressure as follows:
I think that there’s some times when I’ve been extremely pressured for time when I really accelerate the operation to a point that it becomes a very, very different operation. But it’s not an unsafe operation for the patient. (Interview 23, C08)
It appeared to the interviewers that participants could acknowledge that these factors occasionally led to patient harm in practice, but they had difficulty acknowledging them in theory.
Discussion and Conclusions
In daily practice, surgeons strive to do “what is best’” for their patients (i.e., avowed factors) while simultaneously attempting to satisfy numerous competing priorities (i.e., unavowed and disavowed factors). In our study, surgeons described various unavowed and disavowed factors that enter into their intraoperative decision making and are not directly related to the patient. Although such factors are probably reasonable to consider in “real-world” surgical practice, they are not sanctioned in current constructs of patient care based on the “first, do no harm” principle. Thus, it is challenging for surgeons to acknowledge the presence of these factors and to admit that they could have implications for patient safety.
The avowed, unavowed, and disavowed factors identified in our study provide a framework for considering factors that may influence surgeons’ intraoperative decision making. Although the list of factors presented here is not exhaustive, it provides a starting point for considering both the outcome of a surgical case (i.e., whether an error occurs) and the context in which near-misses might occur. We categorized the factors here to illustrate the utility of Ginsburg and colleagues’26 professionalism framework in the context of surgical decision making rather than to make assertions regarding the nature of an individual factor given that the assignment of factors is subjective. As an example of this subjectivity, reluctance to challenge superiors on the hierarchical ladder is becoming less acceptable in the surgical profession. Therefore, making poor clinical decisions based on hierarchical pressure seemed to us to fit better into the disavowed than the avowed category, although this may perhaps still be considered unavowed and understandable to most surgeons. As one surgeon described, “If somebody who is really well respected comes in and does something you don’t really agree with, even though it’s your case, you are going to sort of keep your mouth shut” (Interview 24, C09). This example highlights the underlying cultural and social influences that, to a large extent, determine the categories in which these factors belong. Thus, differences in how individual researchers would categorize factors are not simply the result of researchers’ value systems; rather, they are functions of larger cultural norms, values, and standards. There has been similar discussion in the professionalism literature concerning what is “acceptable” professional behavior.26
Arguably, we could have used other frameworks in the deductive analysis of the data. For example, the standard ethical framework based on the four bioethical principles (i.e., beneficence, nonmaleficence, autonomy, justice) is commonly used in clinical decision making.27 However, these four principles carry an implicit assumption of the avowed factors that focus first and only on the patient; thus, they fail to accommodate the practicalities that surgeons discussed in our study where unavowed and sometimes disavowed factors influence decision making, whether consciously or unconsciously. Also, the ethical framework is more suitable for analyzing extrinsic dilemmas (e.g., a Jehovah’s Witness requiring a blood transfusion) in decision-making processes, whereas professional frameworks may be better suited for the analysis of the intrinsic dilemmas surgeons described in our study.
The discordance in participating surgeons’ perspectives on how these unavowed and disavowed factors influence patient safety illustrates that a tension exists for surgeons between upholding the “acceptable” construct of patient care and negotiating competing priorities. The difficulty surgeons had in linking the influence of these factors with adverse events is likely multifactorial. First, surgeons are usually able to balance multiple priorities well without such balancing leading to adverse events. Second, surgeons likely experience a strong “self-protective” construct because it is emotionally difficult to admit that patient harm results from a personal failure to balance competing priorities appropriately.28 However, as illustrated above by the surgeon’s struggle to rationalize an error in which her resident divided the ureter, it may be that surgeons lack a language to describe the pressures they face within the patient care construct of “first, do no harm,” which does not allow for these concepts.
Our results fit within the larger patient safety movement in several ways. Research has shown that holding surgeons accountable with a “blame and shame” approach promotes a culture of nondisclosure.29,30 However, we would argue that the issue is not simply blaming the surgeon but, rather, that blame is assigned inconsistently by focusing on the outcome (i.e., was there patient harm?) without considering the contextual and cultural factors that may have influenced the surgeon’s decisions. Consider the concept of the “hidden curriculum” in medical education, which refers to the observations that many of the critical determinants of physician identity operate outside the formal curriculum in a more subtle, less recognized curriculum.31,32 A similar concept in surgical practice may be described: Some unavowed principles may be encouraged implicitly, as long as they do not lead to patient harm. For example, a surgeon may hurry through the last case of the day because of organizational pressures to meet efficiency benchmarks, and this may be implicitly sanctioned when it does not lead to complications. However, if this approach results in a complication and the surgeon admits to hurried behavior, the surgeon may be reprimanded because “time pressure” is not an openly and publicly acceptable cause of error (i.e., unavowed factor). Moreover, a successful clinical outcome would not result in the need for personal or public admission of hurried behavior and, thus, would be less likely to evoke critical self-reflection as part of self-regulation.
Amalberti et al33 proposed that risks in complex domains are incurred by experts who challenge the boundaries of their own performance. If surgeons are indeed implicitly encouraged to operate at the limits of their comfort zones (e.g., efficiency is rewarded), then the onus remains on surgeons to self-impose restrictions until guidelines are established at the systems level. The framework presented here might arm surgeons with a language to foster self-regulation. Indeed, making these factors an explicit part of surgeons’ conversations may play an important role in the change process. In other words, if we as surgeons do not talk about it, how can we change it? Where will the pressure to change the culture come from if not from those directly influenced by it? Finally, some of these factors may be irreconcilable within the system (e.g., teaching pressures),34 so providing tools for surgeons to admit, describe, and manage these pressures may be the only way to address the resulting patient safety concerns.
In the context of medical education, the language used in the framework from Ginsburg et al26 offers a meaningful approach for understanding real-world practice decisions and creates a tool for engaging in explicit and effective critical self-reflection on actual practice rather than limiting reflections to ideal situations.28 If surgeons are to develop as self-regulating professionals, it is unrealistic (and potentially dysfunctional) to ignore factors that affect intraoperative decisions but are external to the patient. Acknowledging only ideal scenarios and avowed factors is not helpful for resolving the inevitable tension in balancing multiple priorities or improving patient safety. The current construct of patient care does not require turning a blind eye to influences external to the patient—rather, it requires self-reflection and self-conscious rationalization. Being aware of these external factors and having a language with which to discuss them (i.e., making something that was previously implicit more explicit) may help surgeons self-monitor3 and reflect35,36 in their daily practices. In turn, this may have important implications for the way we educate trainees regarding how to negotiate and navigate unavowed (and disavowed) principles and implications.37
We presented the framework developed by Ginsburg et al26 in the context of surgical practice to raise awareness of changes needed in the surgical culture for surgeons to practice effective self-regulation and full disclosure of serious adverse events.29,38 Our findings suggest that creating a culture of disclosure, emphasizing honesty and transparency, adopting language and a taxonomy to describe factors contributing to errors, and perhaps celebrating this novel approach should lead to improved surgeon well-being and likely to reduction of errors. The contextual factors highlighted in our study should serve as a platform for future explorations into surgical judgment and decision making with implications for patient safety, for surgical teaching, and for fruitful discussions at quality assurance forums.
Funding/Support: This work was supported by the Physicians Services Incorporated Foundation, a Ministry of Research and Innovation Early Researcher Award, and a medical education research grant from the Royal College of Physicians and Surgeons of Canada.
Other disclosures: None.
Ethical approval: This study was approved by the institutional review boards of the University Health Network, Mount Sinai Hospital, and the University of Toronto.
Previous presentations: The abstract of an earlier version of this article was presented at the October 2010 meeting of the Society for Medical Decision Making, Toronto, Canada; the August 2011 meeting of the Association for Medical Education in Europe, Vienna, Austria; the November 2011 Annual Conference on Research in Medical Education, Denver, Colorado; and the April 2012 Canadian Conference on Medical Education, Banff, Canada.
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