Sayra Cristancho

When surgeons face intraoperative challenges: a naturalistic model of surgical decision making.

BACKGROUND Surgery is an environment in which being an expert requires the ability to manage the unexpected. This feature has necessitated a shift in surgical decision-making research. The present study explores the processes by which surgeons assess and respond to nonroutine challenges in the operating room. METHODS We used a grounded theory methodology supported on intraoperative observations and postoperative interviews with 7 faculty surgeons from various specialties. A total of 32 cases were purposively sampled to compile a dataset of challenging situations. RESULTS Thematic data analysis yielded 3 main themes that were linked in a cyclic model: assessing the situation, the reconciliation cycle, and implementing the planned course of action. These elements were connected through 2 points of transition (ie, active and confirmatory reconciliation), during which time the surgeons continue to act although they may change the course of their action. CONCLUSIONS The proposed model builds on existing theories of naturalistic decision making from other high-stakes environments. This model elaborates on a theoretic language that accounts for the unique aspects of surgery, making it useful for teaching in the operating room.

Seeing in Different Ways Introducing “Rich Pictures”in the Study of Expert Judgment

In this article we explore the value of using visual data in a study on medical expert judgment to better understand medical experts’ conceptualizations of complex, challenging situations. We use examples from a larger study on medical expertise in which rich pictures and interviews were used. The three stories presented in this article belong to experts in the domain of surgery. The stories are used to show the ways in which rich pictures can capture and elucidate potentially hidden aspects of the influence of the context in surgical experts’ judgment during challenging operations. We suggest that incorporating visual representations such as rich pictures as research data can aid in understanding previously unarticulated constructions of medical expertise. We conclude that when the researcher strives for capturing complexity, visual methods have the potential to help medical experts deflect from their tendency to simplify descriptions of accounts and to meaningfully engage these individuals in the research process.

What's behind the scenes? Exploring the unspoken dimensions of complex and challenging surgical situations.

Purpose Physicians regularly encounter challenging and/or complex situations in their practices; in training settings, they must help learners understand such challenges. Context becomes a fundamental construct when seeking to understand what makes a situation challenging and how physicians respond to it; however, the question of how physicians perceive context remains largely unexplored. If the goal is to teach trainees to deal with challenging situations, the medical education community requires an understanding of what “challenging” means for those in charge of training. Method The authors relied on visual methods for this research. In 2013, they collected 40 snapshots (i.e., data sets) from a purposeful sample of five faculty surgeons through a combination of interviews, observations, and drawing sessions. The analytical process involved three phases: analysis of each drawing, a compare-and-contrast analysis of multiple drawings, and a team analysis conducted in collaboration with three participating surgeons. Results Findings demonstrate that experts perceive the challenge of surgical situations to extend beyond their procedural dimensions to include unspoken, nonprocedural dimensions—specifically, team dynamics, trust, emotions, and external pressures. Conclusions Findings show that analysis of surgeons’ drawings is an effective means of gaining insight into surgeons’ perceptions. The findings refine the common belief that procedural complexity is what makes a surgery challenging for expert surgeons. Focusing exclusively on the procedure during training may put trainees at risk of missing the “big picture.” Understanding the multidimensionality of medical challenges and having a language to discuss these both verbally and visually will facilitate teaching around challenging situations.

Thresholds of Principle and Preference: Exploring Procedural Variation in Postgraduate Surgical Education.

Background Expert physicians develop their own ways of doing things. The influence of such practice variation in clinical learning is insufficiently understood. Our grounded theory study explored how residents make sense of, and behave in relation to, the procedural variations of faculty surgeons. Method We sampled senior postgraduate surgical residents to construct a theoretical framework for how residents make sense of procedural variations. Using a constructivist grounded theory approach, we used marginal participant observation in the operating room across 56 surgical cases (146 hours), field interviews (38), and formal interviews (6) to develop a theoretical framework for residents’ ways of dealing with procedural variations. Data analysis used constant comparison to iteratively refine the framework and data collection until theoretical saturation was reached. Results The core category of the constructed theory was called thresholds of principle and preference and it captured how faculty members position some procedural variations as negotiable and others not. The term thresholding was coined to describe residents’ daily experiences of spotting, mapping, and negotiating their faculty members’ thresholds and defending their own emerging thresholds. Conclusions Thresholds of principle and preference play a key role in workplace-based medical education. Postgraduate medical learners are occupied on a day-to-day level with thresholding and attempting to make sense of the procedural variations of faculty. Workplace-based teaching and assessment should include an understanding of the integral role of thresholding in shaping learners’ development. Future research should explore the nature and impact of thresholding in workplace-based learning beyond the surgical context.

SCETF: Serious game surgical cognitive education and training framework

Surgical proficiency requires command of both technical and cognitive skills. Although at times overlooked, cognitive skills training allows residents to practise detecting errors ultimately leading to a reduction of errors. Virtual simulations and serious games offer a viable alternative to practice in an actual operating room where traditionally both technical and cognitive skills acquisition takes places. They provide residents the opportunity to train until they reach a specific competency level in a safe, cost effective, fun, and engaging manner allowing them to make more effective use of their limited training time in the operating room. Here we introduce a serious game surgical cognitive education and training framework (SCETF) that is currently being developed specifically for cognitive surgical skills training. Domain-specific surgical “modules” can then be built on top of the existing framework, utilizing common simulation elements/assets. The SCETF is being developed as a research tool where various simulation parameters such as levels of audio and visual fidelity, can be easily adjusted allowing for the controlled testing of such factors on knowledge transfer and retention.

Understanding clinical uncertainty: what is going on when experienced surgeons are not sure what to do?

Purpose In clinical settings, uncertainty is part of everyday practice. However, a lack of insight into how experts approach uncertainty limits the ability to explicitly teach and assess it in training. This study explored how experienced surgeons perceived and handled uncertainty during challenging intraoperative situations, to develop a theoretical language supporting both education and research. Method This constructivist qualitative study included observations and interviews during 26 surgical cases. The cases, drawn from seven staff surgeons from various specialties at a medical school, were purposively sampled after being preidentified by the surgeon as “likely challenging.” The authors combined template and inductive analyses. In template analysis, an existing theory was used to identify instances of uncertainty in the dataset. Inductive analysis was used to elaborate and refine the concepts. Results Template analysis confirmed that existing theoretical concepts are relevant to surgery. However, inductive analysis revealed additional concepts and positioned existing concepts within new relationships. Two new theoretical themes were recognizing uncertainty and responding to uncertainty, each with corresponding subthemes. Factors such as the novelty of the situation, difficulty in predicting the outcome, and difficulty deciding the course of action mainly characterize an uncertain situation in surgery according to the participants. Conclusions The results offer a refined language for conceptualizing uncertainty in surgery. Although further research could elaborate and test the explanatory power of this language, the authors anticipate that it has implications both for current discussions of surgical safety and for future development of explicit training for effective management of surgical uncertainty.

Bringing Community Health Nursing Education to Life with Serious Games

The ever changing needs of society have created a much needed shift in health care delivery from that of hospital to community. However, the role and process of community health nursing is foreign to most nursing students as the majority of nursing curricula continue to relate experiences and examples of nursing to the more familiar role of “nurse clinician.” In contrast to undergraduate nursing programs where the use of simulation and technology has been widely adopted to emphasize the role of the nurse clinician, the use of such technology hasn’t been widely used to address the learning needs of community health nursing students. Here, we present a descriptive paper on the development of an interactive, virtual learning environment (serious game) for acquisition of community health nursing skills. The serious game primarily presents a learner-centered, experiential learning and problem-based learning approach, addressing the learning needs of today’s students.

Eye opener: exploring complexity using rich pictures

Historically, approaches to exploring complexity have mainly focused on the notion that complex problems must be deconstructed into simpler parts if we are to make sense of them; this is the so-called reductionist approach. When dealing with the complexity of human experience, however, deconstructing the experience without diminishing it is a daunting, perhaps impossible task. Researchers wishing to make sense of complex experiences often begin by interviewing the individuals at the centre of those experiences. But interviews can be frustratingly limited. Visual methods, such as drawings, are beginning to show promise for designing research that taps into the complexity of professional practice. The promise of visual methods may relate to a key notion in complexity research: ‘disruptions’. In this paper I introduce the notion of ‘disruptions’ as articulated by complexity approaches from ‘systems engineering’ and suggest ‘rich pictures’ as an effective visual method to describe and understand complex problems in medical education research.

‘Oh my God, I can't handle this!’: trainees’ emotional responses to complex situations

Dealing with emotions is critical for medical trainees’ professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations.

How would you call this in English

IntroductionMedical education researchers increasingly collaborate in international teams, collecting data in different languages and from different parts of the world, and then disseminating them in English-language journals. Although this requires an ever-present need to translate, it often occurs uncritically. With this paper we aim to enhance researchers’ awareness and reflexivity regarding translations in qualitative research.MethodsIn an international study, we carried out interviews in both Dutch and English. To enable joint data analysis, we translated Dutch data into English, making choices regarding when and how to translate. In an iterative process, we contextualized our experiences, building on the social sciences and general health literature about cross-language/cross-cultural research.ResultsWe identified three specific translation challenges: attending to grammar or syntax differences, grappling with metaphor, and capturing semantic or sociolinguistic nuances. Literature findings informed our decisions regarding the validity of translations, translating in different stages of the research process, coding in different languages, and providing ‘ugly’ translations in published research reports.DiscussionThe lessons learnt were threefold. First, most researchers, including ourselves, do not consciously attend to translations taking place in international qualitative research. Second, translation challenges arise not only from differences in language, but also from cultural or societal differences. Third, by being reflective about translations, we found meaningful differences, even between settings with many cultural and societal similarities. This conscious process of negotiating translations was enriching. We recommend researchers to be more conscious and transparent about their translation strategies, to enhance the trustworthiness and quality of their work.