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"Contemplating the next maneuver": functional neuroimaging reveals intraoperative decision-making strategies

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Title: "Contemplating the next maneuver": functional neuroimaging reveals intraoperative decision-making strategies
Authors: Leff, DR
Yongue, G
Vlaev, I
Orihuela-Espina, F
James, D
Taylor, MJ
Athanasiou, T
Dolan, R
Yang, GZ
Darzi, A
Item Type: Journal Article
Abstract: OBJECTIVE: To investigate differences in the quality, confidence, and consistency of intraoperative surgical decision making (DM) and using functional neuroimaging expose decision systems that operators use. SUMMARY BACKGROUND DATA: Novices are hypothesized to use conscious analysis (effortful DM) leading to activation across the dorsolateral prefrontal cortex, whereas experts are expected to use unconscious automation (habitual DM) in which decisions are recognition-primed and prefrontal cortex independent. METHODS: A total of 22 subjects (10 medical student novices, 7 residents, and 5 attendings) reviewed simulated laparoscopic cholecystectomy videos, determined the next safest operative maneuver upon video termination (10 s), and reported decision confidence. Video paradigms either declared ("primed") or withheld ("unprimed") the next operative maneuver. Simultaneously, changes in cortical oxygenated hemoglobin and deoxygenated hemoglobin inferring prefrontal activation were recorded using Optical Topography. Decision confidence, consistency (primed vs unprimed), and quality (script concordance) were assessed. RESULTS: Attendings and residents were significantly more certain (P < 0.001), and decision quality was superior (script concordance: attendings = 90%, residents = 78.3%, and novices = 53.3%). Decision consistency was significantly superior in experts (P < 0.001) and residents (P < 0.05) than novices (P = 0.183). During unprimed DM, novices showed significant activation of the dorsolateral prefrontal cortex, whereas this activation pattern was not observed among residents and attendings. During primed DM, significant activation was not observed in any group. CONCLUSIONS: Expert DM is characterized by improved quality, consistency, and confidence. The findings imply attendings use a habitual decision system, whereas novices use an effortful approach under uncertainty. In the presence of operative cues (primes), novices disengage the prefrontal cortex and seem to accept the observed operative decision as correct.
Issue Date: 1-Feb-2017
Date of Acceptance: 1-Feb-2017
URI: http://hdl.handle.net/10044/1/29057
DOI: 10.1097/SLA.0000000000001651
ISSN: 1528-1140
Publisher: Lippincott, Williams &amp; Wilkins
Start Page: 320
End Page: 330
Journal / Book Title: Annals of Surgery
Volume: 265
Issue: 2
Replaces: 10044/1/45337
http://hdl.handle.net/10044/1/45337
Copyright Statement: © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Sponsor/Funder: The Academy of Medical Sciences
National Institute for Health Research
Engineering & Physical Science Research Council (EPSRC)
Engineering & Physical Science Research Council (EPSRC)
National Institute of Health Research
Funder's Grant Number: Dan Leff Starter Grant
NF-SI-0510-10186
EP/N027132/1
EP/J021199/1
Keywords: Science & Technology
Life Sciences & Biomedicine
Surgery
brain
decision making
functional near-infrared spectroscopy
prefrontal
simulation
surgery
training
BILE-DUCT INJURIES
LAPAROSCOPIC CHOLECYSTECTOMY
OPERATING-ROOM
SURGEONS
BRAIN
UNCERTAINTY
PERFORMANCE
ACTIVATION
CORTEX
RISK
Adult
Cholecystectomy, Laparoscopic
Decision Making
Female
Functional Neuroimaging
Humans
Intraoperative Period
Male
Middle Aged
Prefrontal Cortex
Students, Medical
Surgeons
Video Recording
Prefrontal Cortex
Humans
Cholecystectomy, Laparoscopic
Intraoperative Period
Decision Making
Students, Medical
Video Recording
Adult
Middle Aged
Female
Male
Functional Neuroimaging
Surgeons
Surgery
11 Medical and Health Sciences
Publication Status: Published
Conference Place: United States
Appears in Collections:Department of Surgery and Cancer
Institute of Global Health Innovation
Faculty of Engineering