LAUSR

A ll surgeries have the potential to inflict harm. As a specialty, surgeons are especially cognizant of the inherent risk of surgical interventions. Patients rely on surgeon’s recommendations when making the decisions for care. It is of great interest, therefore, to understand the factors that influence surgeon’s judgment in recommending for or against an operation. As theorized by behavioral psychologist Daniel Kahneman, human decisions are based on an interplay between 2 distinct cognitive processes: rationality vs intuition. In their recent study, Sacks et al attempted to answer how these 2 processes contribute to the decision making of surgeons. The investigators designed a national Internet-based survey of practicing surgeons and trainees, in which they provided 4 purposely ambiguous clinical scenarios focused on appendicitis, cholangitis, small bowel obstruction, and gastrointestinal bleeding. They queried each respondent regarding 4 categories of perception (operative risk, operative benefit, nonoperative risk, and nonoperative benefit), and whether or not they would operate on the patient. There was a wide variation in the participants’ decisions to operate (48.9–84.5%). Not surprisingly, the recommendation for operation is significantly associated with the perception of high operative benefit and low operative risk. The investigators found this association to be even stronger with nonoperative benefit and risk. These findings imply that surgeons are making rational decisions in line with perceived risk and benefit. However, the process of determining risk and benefit itself relies much on surgeon’s intuition. Often times there are little objective data available for nonoperative risk and benefit. Aiming to better grasp the intangible elements in risk perception, the investigators embedded a second study in the same survey. A different cohort of participants was randomly assigned to use the National Safety and Quality Improvement Program operative risk calculator before querying risk and benefit perceptions. Surgeons’ responses in the group with previous exposure to risk calculator display a significantly less variation in operative risk and benefit perception, and they approximate more closely to the values of the risk calculator compared to the unexposed control group. Interestingly, although the risk calculator focuses only on operative risk, the exposed surgeons showed a significant difference in every other category, including nonoperative risk and benefit. The impact of the risk calculator on other unrelated categories supports the presence of irrational factors in surgeons’ risk and benefit perception. Further research is needed to better understand the potential bias in surgeons’ decision-making process. In order to optimize patients’ well-being, the author suggests that surgeons should make an effort to dissociate operative and nonoperative risk and benefit, and actively involve the patient in the decision-making process through elucidation of their preferences.