Laurent St-Martin, MSc.

The ongoing transition towards a more structured model of surgical training relies on formal and explicit teaching and assessment of specific competencies. However, judgment remains an elusive construct that is challenging to teach and assess. A recent series of studies identified the phenomenon of “slowing down” in response to critical intraoperative cues as a hallmark of expert surgical judgment. As a first step towards teaching and assessment of surgical judgment, the purpose of this project was to explore a novel approach to capturing the “slowing down” moments of surgical practice under standardized conditions, combining the think aloud method with videotaped surgical procedures.

Edited videos of laparoscopic cholecystectomies (LCs) were shown to ten expert surgeons (>250 LCs completed and performing LCs on a regular basis in their current practice). Participants were asked to think aloud while watching the videos as if observing each procedure in the operating room. The think aloud transcripts formed the data set. We then made an effort to isolate the participants’ “slowing down” moments within the transcripts using Moulton’s descriptions of “slowing down” as a guide. Although the approach was more complicated than anticipated, it allowed us to capture a great number of “slowing down” moments, some of which would have been difficult (if not impossible) to capture using other methods. For example, the detection and deliberate avoidance of a critical structure might not be associated with an observable behaviour. Moreover, the standardized format (watching a series of videos) made it possible to compare “slowing down” moments between individual surgeons.

A subset of “slowing down” moments which we termed the “moments of concern” (MCs) was compared between the ten expert participants. It was our hope that expert participants would experience similar “slowing down” moments which could then be used to create novel teaching and assessment tools. Some MCs showed high agreement. However, the main finding was considerable variation in MCs between participants. These results further our understanding that expert judgment is complex and variable between experts. Further research is required to understand how surgical judgment might best be taught and assessed in light of the possibility that a “gold standard” of judgment might not exist.