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“And I Think That We Can Fix It”

Mental Models Used in High-risk Surgical Decision Making

Kruser, Jacqueline M. MD*; Pecanac, Kristen E. MS, RN; Brasel, Karen J. MD, MPH; Cooper, Zara MD, MSc§; Steffens, Nicole M. MPH; McKneally, Martin F. MD, PhD‖,**; Schwarze, Margaret L. MD, MPP¶,††

doi: 10.1097/SLA.0000000000000714
Original Articles

Objective: To examine how surgeons use the “fix-it” model to communicate with patients before high-risk operations.

Background: The “fix-it” model characterizes disease as an isolated abnormality that can be restored to normal form and function through medical intervention. This mental model is familiar to patients and physicians, but it is ineffective for chronic conditions and treatments that cannot achieve normalcy. Overuse may lead to permissive decision making favoring intervention. Efforts to improve surgical decision making will need to consider how mental models function in clinical practice, including “fix-it.”

Methods: We observed surgeons who routinely perform high-risk surgery during preoperative discussions with patients. We used qualitative content analysis to explore the use of “fix-it” in 48 audio-recorded conversations.

Results: Surgeons used the “fix-it” model for 2 separate purposes during preoperative conversations: (1) as an explanatory tool to facilitate patient understanding of disease and surgery, and (2) as a deliberation framework to assist in decision making. Although surgeons commonly used “fix-it” as an explanatory model, surgeons explicitly discussed limitations of the “fix-it” model as an independent rationale for operating as they deliberated about the value of surgery.

Conclusions: Although the use of “fix-it” is familiar for explaining medical information to patients, surgeons recognize that the model can be problematic for determining the value of an operation. Whether patients can transition between understanding how their disease is fixed with surgery to a subsequent deliberation about whether they should have surgery is unclear and may have broader implications for surgical decision making.

The “fix-it” model of decision making assumes that medical conditions are acute abnormalities that can be readily and completely addressed through medical intervention. This model is familiar to physicians and patients, but surgeons view it as problematic for complex, high-risk surgical decisions.

*Department of Medicine and

School of Nursing, University of Wisconsin, Madison

Department of Surgery, Medical College of Wisconsin, Milwaukee

§Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA

Department of Surgery, Division of Vascular Surgery, University of Wisconsin, Madison

Department of Surgery and

**Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada

††Department of Medical History and Bioethics, University of Wisconsin, Madison.

Reprints: Margaret L. Schwarze, MD, MPP, Department of Surgery, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, G5/315 CSC, 600 Highland Avenue, Madison, WI 53792. E-mail:

Disclosure: The project described was supported by the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant 1UL1RR025011 and now by the National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427 (M.L.S.). This project was also supported by the Greenwall (Kornfeld) Program for Bioethics and Patient Care (M.L.S.) and the American Geriatrics Society Jahnigen Career Development Award, grant 1R03AG042361-01 NIH (Z.C.). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the manuscript for publication. No other financial support was declared for the remaining authors.

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