title: Dissecting Attending Surgeons' Operating Room Guidance: Factors That Affect Guidance Decision Making.
abstract: OBJECTIVE
  The amount of guidance provided by the attending surgeon in the operating room (OR) is a key element in developing residents' autonomy. The purpose of this study is to explore factors that affect attending surgeons' decision making regarding OR guidance provided to the resident.
  
  
  METHODS
  We used video-stimulated recall interviews (VSRI) throughout this 2-phase study. In Phase 1, 3 attending surgeons were invited to review separately 30 to 45 minute video segments of their prerecorded surgical operations to explore factors that influenced their OR guidance decision making. In Phase 2, 3 attending surgeons were observed and documented in the OR (4 operations, 341min). Each operating surgeon reviewed their videotaped surgical performance within 5 days of the operation to reflect on factors that affected their decision making during the targeted guidance events. All VSRI were recorded. Thematic analysis and manual coding were used to synthesize and analyze data from VSRI transcripts, OR observation documents, and field notes.
  
  
  RESULTS
  A total of 255 minutes of VSRI involving 6 surgeons and 7 surgical operations from 5 different procedures were conducted. A total of 13 guidance decision-making influence factors from 4 categories were identified (Cohen's κ = 0.674): Setting (case schedule and patient morbidity), content (procedure attributes and case progress), resident (current competency level, trustworthiness, self-confidence, and personal traits), and attending surgeon (level of experience, level of comfort, preferred surgical technique, OR training philosophy, and responsibility as surgeon). A total of 5 factors (case schedule, patient morbidity, procedure attributes, resident current competency level, and trustworthiness) influenced attending surgeons' pre-OR guidance plans. "OR training philosophy" and "responsibility as surgeon" were anchor factors that affected attending surgeons' OR guidance decision-making patterns.
  
  
  CONCLUSIONS
  Surgeons' OR guidance decision making is a dynamic process that is influenced by 13 situational factors. These factors can be used by residency programs to tailor strategies designed to increase resident autonomy in the OR.
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts. Electronic address: xpchen@partners.org.
authors.forename: Xiaodong Phoenix
authors.initials: XP
authors.lastname: Chen
authors.affiliation: Department of Surgery, Indiana University, Indianapolis, Indiana.
authors.forename: Reed G
authors.initials: RG
authors.lastname: Williams
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Smink
mesh_terms: D003657:Decision Making; D004503:Education, Medical, Graduate / Q000379:methods; D013502:General Surgery / Q000193:education*; D006801:Humans; D007396:Internship and Residency; D007407:Interviews as Topic; D008505:Medical Staff, Hospital; D009873:Operating Rooms; D017410:Practice Guidelines as Topic
keywords: Interpersonal Communication Skills; OR teaching; Patient Care; Practice-Based Learning and Improvement; Professionalism; decision making; operating room (OR) guidance; resident autonomy; surgical education