A tool for training in decision making for emergency general surgery--explicit training is possible through facilitation.
BACKGROUND
Emergency general surgery is increasingly recognized as an area for improvement within the National Health Service in the United Kingdom. Our aim was to test the feasibility of a tool we developed in assessing and facilitating surgical decision making by trainees in the emergency setting.


METHODS
A decision-making tool based on common decisions in surgery was designed and incorporated prospectively into patient clerking. The 10 decisions available to surgeons were divided into 3 major headings: discharge decisions, observation decisions, and operative decisions. "Ideal decisions" were derived from the final diagnosis on discharge by 2 independent clinicians and compared with initial decisions made by surgeons. We analyzed the data with a view to validate the tool using 2 methods. Firstly, we looked at the percentage of correct decisions made by different grades of surgeon, and secondly, we analyzed the trends in deviations from ideal decisions.


RESULTS
The decision-making tool was completed for 136 emergent surgical admissions over 2 months. Interns made less "ideal" decisions compared with residents (45% vs 56%, respectively; p = 0.10, Fisher exact test) and attending surgeons (45% vs 70%, respectively; p = 0.0001). Interns made more "admit and observe or investigate" decisions compared with residents (63% vs 55%, respectively; p = 0.27) and attending surgeons (63% vs 51%, respectively; p = 0.01), who were more likely to decide to operate on or discharge patients. A repeat study over the subsequent 2-month period has shown comparable findings in proportion of ideal decisions for each grade of surgeon.


CONCLUSIONS
There are significant differences in the proportion of "ideal decisions" and types of decisions between interns and attending surgeons suggesting a learning curve and potential for using this tool in decision-making training. The tool inherently facilitates discussion over decisions made by making these explicit. Repeating the study revealed an internal consistency.
Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' Hospital, London, United Kingdom.
Zita M
ZM
Jessop
Department of General Surgery, Chelsea and Westminster Hospital, London, United Kingdom. Electronic address: nebil.behar@chelwest.nhs.uk.
Nebil
N
Behar
D002983:Clinical Competence; D003430:Cross-Sectional Studies; D003657:Decision Making; D013502:General Surgery / Q000193:education*; D006801:Humans; D059032:Learning Curve; D013222:State Medicine; D006113:United Kingdom
Patient Care; Practice-Based Learning and Improvement; Systems-Based Practice; decision making; emergency surgery; general surgery; surgical training