Use of hypothetical cases to investigate indications for surgery

Hypothetical case histories were used to investigate judgements to operate or to refer. Six procedures (cholecystectomy, colectomy, inguinal herniorrhaphy, tonsillectomy, cesarean section and hysterectomy) were selected and four cases were developed for each procedure. Control cases were those on which surgeons agreed and test cases were those on which there was disagreement regarding surgical or nonsurgical treatment. The case histories were mailed to 131 surgeons and referring physicians in one Ontario county. Among the 98 respondents 75% indicated that the cases were typical of problems seen in practice. This paper reviews the case histories and results for cholecystectomy and hysterectomy. Two of the cholecystectomy cases were controls with 83% of the surgeons opting for nonsurgical treatment in one and 94% opting for surgery in the other. For hysterectomy there was one control case with 90% agreement among gynecologists to operate; in the three test cases from 25% to 75% of the gynecologists favoured surgery. The combined results of all test cases indicated that younger surgeons were less likely to select operation than older surgeons. No consistent sociodemographic associations with the referral decision could be determined for referring physicians, possibly owing to the small sample size.