title: Thinking like an expert: surgical decision making as a cyclical process of being aware.
abstract: BACKGROUND
  Education researchers are studying the practices of high-stake professionals as they learn how to better train for flexibility under uncertainty. This study explores the "Reconciliation Cycle" as the core element of an intraoperative decision-making model of how experienced surgeons assess and respond to challenges.
  
  
  METHODS
  We analyzed 32 semistructured interviews using constructivist grounded theory to develop a model of intraoperative decision making. Using constant comparison analysis, we built on this model with 9 follow-up interviews about the most challenging cases described in our dataset.
  
  
  RESULTS
  The Reconciliation Cycle constituted an iterative process of "gaining" and "transforming information." The cyclical nature of surgeons' decision making suggested that transforming information requires a higher degree of awareness, not yet accounted by current conceptualizations of situation awareness.
  
  
  CONCLUSIONS
  This study advances the notion of situation awareness in surgery. This characterization will support further investigations on how expert and nonexpert surgeons implement strategies to cope with unexpected events.
authors.affiliation: Department of Surgery and Centre for Education Research & Innovation, University of Western Ontario, London, Ontario, Canada. Electronic address: sayra.cristancho@schulich.uwo.ca.
authors.forename: Sayra M
authors.initials: SM
authors.lastname: Cristancho
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.
authors.forename: Tavis
authors.initials: T
authors.lastname: Apramian
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Meredith
authors.initials: M
authors.lastname: Vanstone
authors.affiliation: Department of Medicine and Centre for Education Research & Innovation, University of Western Ontario, London, Ontario, Canada.
authors.forename: Lorelei
authors.initials: L
authors.lastname: Lingard
authors.affiliation: Division of General Surgery, Department of Surgery, University of Western Ontario, London, Ontario, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Ott
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Thomas
authors.initials: T
authors.lastname: Forbes
authors.affiliation: Department of Critical Care, University of Calgary, Calgary, Alberta, Canada; Department of Cardiac Sciences and Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Novick
mesh_terms: D000223:Adaptation, Psychological; D001364:Awareness; D000066491:Clinical Decision-Making / Q000379:methods*; D005500:Follow-Up Studies; D066296:Grounded Theory; D006801:Humans; D007407:Interviews as Topic; D007432:Intraoperative Period; D008960:Models, Psychological; D036301:Qualitative Research; D066231:Surgeons / Q000523:psychology*; D035501:Uncertainty
keywords: Decision making; Reconciliation cycle; Situation awareness; Surgery