Expertise and Metacognition in Laparoscopic Surgery: A Field Study

Abstract

In challenging cases, surgeons continually assess whether the patient's best interests might be served by converting a laparoscopic case to an open-incision one. Converting in many ways widens the scope and quality of perceptual information available to the surgeon. This research focused on surgical decision making in the context of the decision to convert. A cognitive task analysis effort, involving field observations and a research study, was undertaken to elicit information about decisions made during surgery. Ten experienced (staff) and ten senior resident surgeons were shown videotape from a difficult laparoscopic surgery case. The surgeons responded to structured questions at critical points in the procedure and also provided running commentary as the operation unfolded. Approximately half of the surgeons decided that the case should be converted to an open procedure at some point during the operation. The verbal protocols were analyzed to identify differences as a function of expertise (staff vs. resident) and of the conversion decision (opener vs. nonopener). Staff surgeons expressed awareness of boundary conditions to safe operation more frequently. Further, there was evidence of inappropriately high levels of confidence, yet little evidence of self-criticism (metacognition), among residents who chose not to open.