Department of Medicine Publications

Operating from the Other Side of the Table: Control Dynamics and the Surgeon Educator

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Journal of the American College of Surgeons





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BACKGROUND: Critical moments in operations cause the surgeon to transition from a relatively "automatic" mode of operating to a more attentive mode-previously referred to as "slowing down when you should." Using this framework, this study explored how academic surgeons manage and balance the often competing responsibilities of patient safety and education during the slowing-down moments.

STUDY DESIGN: This study used a constructivist approach to grounded theory methodology to explore an emergent theme of control among academic surgeons. Twenty-eight surgeons were interviewed across 4 academic teaching hospitals, and 5 general (hepato-pancreatico-biliary) surgeons were observed. Thematic analysis of the transcripts and field notes was conducted and iteratively elaborated and refined as data collection progressed with all team members. A reflexive approach was adopted throughout.

RESULTS: An interesting control dynamic emerged as surgeons discussed the need to maintain a sense of control of an operation regardless of how much manual control they had. A dual responsibility to education and patient safety was apparent, with surgeons describing and demonstrating numerous strategies for negotiating manual control with the trainee during the critical slowing-down moments. An assessment of the trainee was implicit in the negotiation process. Numerous complications of control were identified ("bargaining," "skidding") as a product of this control dynamic.

CONCLUSIONS: Operating from the "other side of the table" sets up a control dynamic that requires manipulation and negotiation on the part of the academic surgeon. Understanding these issues informs surgeons in their supervisory role, offering avenues for optimizing surgical training.


Dr. Lorelei Lingard is currently a faculty member at The University of Western Ontario.

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