Another factor contributing to the tendency of surgeons to overwork is the workforce shortage. Heavy
caseloads may make it difficult to find time for attention to the behavioral elements of care. Combine this
lack of opportunity for self-reflection with a failure to
grasp the profound significance of our behavior, and
errors are the inevitable result. We stop communicating. We examine images instead of patients, focusing all
too often on incidental imaging or lab findings instead
of patient complaints. We make decisions on the basis
of numbers on a monitor reported to us by surrogates
without the benefit of clinical correlation. We proceed
without taking time for necessary forethought.
Good professional behavior enhances a surgeon’s
knowledge base and technical skill and helps him or
her avoid errors and achieve the best possible outcomes.
Especially when we are overworked and fatigued,
we must slow down in order to accomplish ordinary
tasks. Medical knowledge should be adequate if we
work within a proper scope of practice, take the necessary time to seek and find additional information when
needed, and consult as appropriate.
Errors and cognitive skills
In the Harvard medical practice study cited previously,
mistakes in judgment were observed in 169 of the 258
claims that resulted from errors, but the investigators
made no specific reference to cognition. 8 However,
the surgeon reviewers who collected information for
the ACS Closed Claims Study reported a complex rela-
tionship between medical knowledge, behavior, and
cognition, although no specific data were collected. 6
Other researchers have estimated that 80 percent of
misdiagnoses stem from cognitive errors. 4 Although
difficult to measure, it is clear that cognitive errors are
common and frequently have disastrous results.
Taking time to think is an aspect of diligent behavior; having the cognitive ability with which to think
also is important. However, these qualities are not
mutually exclusive; cognitive diligence and cognitive
skill are both necessary to minimize errors.
In How Doctors Think, Jerome Groopman, MD, clarifies the complex interaction between thinking and
knowledge. 11 The ability to recognize when we do not
know something can be used to prompt skillful thinking. Realizing that what we know is based only on a
modest level of understanding, we learn to thoughtfully
challenge what we think we know when it is questioned or when facts and data do not fit that piece of
knowledge. Clinical certainty on the part of a surgeon
can sometimes stymie meaningful thinking when it is
used defensively to hide uncertainty. Uncertainty can
be helpful and lead to reflective cognition, which is a
tool for dealing with the care of a patient that involves
conflicting facts or data.
Dr. Groopman defines several types of cognitive
mistakes that lead to medical errors. He illustrates these
ACS CLOSED CLAIMS STUDY:
PREVENTABILITY OF COMPLICATION BY OCCURRENCE OF
TECHNICAL ERROR AND BEHAVIOR VIOLATIONS, N (%)
Preventability of complication
n = 360
n = 100 Row total
When technical error occurs* n = 173 n = 56 n = 229
Preventable 134 (78) 25 ( 45) 159 (69)
Not preventable 6 ( 4) 19 ( 34) 25 ( 11)
Impossible to judge 33 ( 19) 12 ( 21) 45 ( 20)
When no technical error occurs† n = 187 n = 44 n = 231
Preventable 76 ( 41) 0 (0) 76 ( 33)
Not preventable 28 ( 15) 34 (77) 62 ( 27)
Impossible to judge 83 ( 44) 10 ( 23) 93 ( 40)
*Chi-square = 42.635, df = 2 (p < 0.000).
†Chi-square = 73.540, df = 2 (p < 0.000).
Adapted from Griffen FD, Stephens LS, Alexander, JB, et al. Violations of behavioral practices
revealed in closed claims reviews. Ann Surg. 2008;248( 3):468-474. Used with permission.