Thinking like an expert: surgical decision making as a cyclical process of being aware

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. (C) 2016 Elsevier Inc. All rights reserved.