"First, do no harm":  balancing competing priorities in surgical practice.
OBJECTIVE
To explore surgeons' perceptions of the factors that influence their intraoperative decision making, and implications for professional self-regulation and patient safety.


METHODS
Semistructured interviews were conducted with 39 academic surgeons from various specialties at four hospitals associated with the University of Toronto Faculty of Medicine. Purposive and theoretical sampling was performed until saturation was achieved. Thematic analysis of the transcripts was conducted using a constructivist grounded-theory approach and was iteratively elaborated and refined as data collection progressed. A preexisting theoretical professionalism framework was particularly useful in describing the emergent themes; thus, the analysis was both inductive and deductive.


RESULTS
Several factors that surgeons described as influencing their decision making are widely accepted ("avowed," or in patients' best interests). Some are considered reasonable for managing multiple priorities external to the patient but are not discussed openly ("unavowed," e.g., teaching pressures). Others are actively denied and consider the surgeon's best interests rather than the patient's ("disavowed," e.g., reputation). Surgeons acknowledged tension in balancing avowed factors with unavowed and disavowed factors; when directly asked, they found it difficult to acknowledge that unavowed and disavowed factors could lead to patient harm.


CONCLUSIONS
Some factors that are not directly related to the patient enter into surgeons' intraoperative decision making. Although these are probably reasonable to consider within "real-world" practice, they are not sanctioned in current patient care constructs or taught to trainees. Acknowledging unavowed and disavowed factors as sources of pressure in practice may foster critical self-reflection and transparency when discussing surgical errors.
University of Toronto Faculty of Medicine, Department of Surgery, Wilson Centre, University Health Network and University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
Annie
A
Leung
Shelly
S
Luu
Glenn
G
Regehr
M Lucas
ML
Murnaghan
Steven
S
Gallinger
Carol-Anne
CA
Moulton
D001291:Attitude of Health Personnel; D003657:Decision Making / Q000941:ethics*; D006801:Humans; D007407:Interviews as Topic; D007430:Intraoperative Care / Q000941:ethics* / Q000523:psychology / Q000592:standards; D019300:Medical Errors / Q000941:ethics* / Q000517:prevention & control / Q000523:psychology; D008962:Models, Theoretical; D009042:Motivation; D009864:Ontario; D061214:Patient Safety; D010820:Physicians / Q000941:ethics* / Q000523:psychology / Q000592:standards; D017009:Professional Autonomy; D011582:Psychological Theory; D013043:Specialties, Surgical / Q000193:education / Q000941:ethics* / Q000592:standards