"First, do no harm": balancing competing priorities in surgical practice.

Area of Science:

• Medical Professionalism
• Surgical Decision Making
• Patient Safety

Background:

• Intraoperative decision-making is complex.
• Understanding influencing factors is crucial for patient safety.
• Professionalism frameworks guide surgical practice.

Purpose of the Study:

• To explore surgeons' perceptions of factors influencing intraoperative decisions.
• To examine implications for professional self-regulation.
• To assess impact on patient safety.

Main Methods:

• Semistructured interviews with 39 academic surgeons.
• Thematic analysis using constructivist grounded theory.
• Inductive and deductive analysis informed by professionalism framework.

Main Results:

• Surgeons identified 'avowed' (patient interests), 'unavowed' (e.g., teaching), and 'disavowed' (e.g., reputation) factors.
• Tension exists in balancing these factors.
• Difficulty acknowledging potential patient harm from unavowed/disavowed factors.

Conclusions:

• Non-patient-related factors influence surgical decisions.
• These factors, though practical, are not formally sanctioned in training.
• Acknowledging these pressures can improve self-reflection and error discussion.