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Pressures to “Measure Up” in Surgery: Managing Your Image and Managing Your Patient

Jin, Chunzi Jenny*; Martimianakis, Maria Athina MA, MEd, PhD; Kitto, Simon PhD; Moulton, Carol-anne E. MBBS, FRACS, MEd, PhD§

doi: 10.1097/SLA.0b013e3182583135
Original Articles

Objective: To identify pressures created by surgical culture and social setting and explore mechanisms for how they might impact operative decision-making.

Background: Surgeons apply judgments within a powerful social context and are constantly socialized and influenced by communicative exchanges. In this study, the authors characterized the nature of the surgical social context, focusing on the interactions between external social influences and the cognitive ability of the surgeon to respond to uncertain, unexpected, or critical moments in operations.

Methods: The authors reviewed the sociological and psychosocial literatures to examine concepts in identity construction, socialization process, and image management literatures and synthesized a conceptual framework allowing for the examination of how social factors and image management might impact surgical performance.

Results: The surgeon's professional identity is constructed and negotiated on the basis of the context of surgical culture. Trainees are socialized to display confidence and certainty as part of the “hidden curriculum” and several sociocultural mechanisms regulating “appropriate” surgical behavior exist in this system. In the image management literature, individuals put on a “front” or social performance that is socially acceptable. Several mechanisms for how image management might impact surgical judgment and decision-making were identified through an exploration of the cognitive psychology literature.

Conclusions: Sociopsychological literatures can be linked with decision-making and cognitive capacity theory. When cognitive resources reach their limit during critical and uncertain moments of an operation, the consumption of resources by the pressures of reputation and ego might interfere with the thought processes needed to execute the task at hand. Recognizing the effects of external social pressures may help the surgeon better self-regulate, respond mindfully to these pressures, and prevent surgical error.

Surgical decision-making occurs in the context of the surgical social scene, and it is unlikely to be immune to these environmental influences. In this study, the authors reviewed the sociological and sociopsychological literature to characterize how social factors and pressures on surgeons to “perform” may impinge on surgeon cognition and decision-making.

*Faculty of Medicine, University of Toronto

Department of Paediatrics; Wilson Centre for Research in Education; Centre for Faculty Development; Faculty of Medicine, University of Toronto; Hospital for Sick Children

Li Ka Shing Knowledge Institute of St Michael's Hospital; Department of Surgery; Wilson Centre for Research in Education; and Office of Continuing Education and Professional development University of Toronto

§Department of Surgery, University of Toronto; Hepatobiliary & Pancreatic Surgical Oncology, University Health Network; and Wilson Centre for Research in Education.

Reprints: Carol-anne E. Moulton, MBBS, FRACS, MEd, PhD, The Wilson Centre for Research in Education, Toronto General Hospital, 200 Elizabeth St., Eaton Sth 1–565, Toronto, ON M5G2C4, Canada, E-mail:

Disclosure: This study has been supported by Physician's Services Incorporated Grant and Early Researcher Award from the Ministry of Research and Innovation.

© 2012 Lippincott Williams & Wilkins, Inc.