Influencing factors in surgical decision‐making: a qualitative analysis of colorectal surgeons' experiences of postoperative complications

When making anastomotic decisions in rectal cancer surgery, surgeons must consider the risk of anastomotic leakage, which bears implications for the patient's quality of life, cancer recurrence and, potentially, death. The aim of this study was to investigate the views of colorectal surgeons on how their individual attributes (e.g. experience, personality traits) may influence their decision‐making and experience of complications.


INTRODUC TI ON
Anastomotic leakage remains one of the most significant surgical complications for colorectal surgeons due to its negative consequences for patients in the short term (e.g.multiorgan failure with critical care admission, return to theatre) [1, 2] and longer term (e.g.poorer oncological outcomes and bowel function) [3,4].These consequences culminate in poorer quality of life and significant risk of death for the patient [2].The risk of an anastomotic leak is influenced by multiple factors, which may be related to the patient (e.g.comorbidities) [5], pathology (e.g.low tumour height, neoadjuvant chemoradiotherapy) [6], technique (e.g.use of preoperative antibiotics and mechanical bowel preparation, tension-free anastomosis) [7,8] or surgeon (e.g.training and cognitive factors, i.e. risk-taking preferences and personality) [9][10][11].
Surgeon-specific factors may also influence the risk of anastomotic leakage.For example, the clinician's gender has been associated with patient outcomes in both operative [12] and nonoperative settings [13,14].Earlier work from this group indicated that the surgeon's personality influences variation in rectal anastomotic practice and stoma formation [11,15].However, little is known about how postoperative outcomes, including anastomotic leakage, may intersect with surgeon-specific factors such as gender and impact later clinical decision-making.Moreover, previous studies of general and vascular surgeons have indicated that complications cause surgeons psychological and physical distress [16][17][18][19].Importantly, patients also believe surgeon personality to be a major determinant of the management of postoperative complications [20].Better understanding of how surgeons make anastomotic decisions, how they respond to complications consequent upon their decision (e.g.anastomotic leaks) and how their experience of anastomotic leaks may influence later decision-making could provide an opportunity to support surgeons and optimize technical performance [21] by identifying targeted supportive interventions for surgeons, and thus improve patient outcomes.
We therefore aimed to investigate the views of colorectal surgeons on how their individual attributes (such as training experiences, personality and risk-taking preferences) may influence surgical decision-making in the context of a colorectal anastomosis.
Our secondary aim was to gain a deeper insight into decision-making following an anastomotic leak.

ME THOD
This was a qualitative study using semi-structured individual interviews for data collection.The full topic guide can be found in Appendix S1.Interview findings are reported using the COREQ 32item checklist as a framework (Appendix S2) [22].Ethical approval was obtained from the University of Aberdeen School of Medicine, Medical Sciences and Nutrition Ethics Review Board (SERB) (SERB/2022/3/2268).

Study design
The topic guide was developed from relevant literature on qualitative interview studies in healthcare [23,24] and findings from recent work on individual variation in practice [15].All items in the topic guide were reviewed and agreed upon by the research team.The topic guide was piloted on a trainee surgeon prior to recruitment.

Participant selection
Purposive sampling was used [25].Surgeons who had participated in earlier work on surgeon personality by this authorship group (the Plato Project) [15] were invited to participate.Other UK-based surgeons who were certified surgeons (i.e.experts not trainees) who met the Association of Coloproctology of Great Britain and Ireland (ACPGBI) definition of a colorectal specialist surgeon at time of protocol development (independently perform more than 20 elective colorectal cancer operations per year and contribute to multidisciplinary team discussions) [26] were also invited to participate via social media and email advertisements from ACPGBI newsletters.UK-based surgeons were chosen to gain deeper insight into the specific training experiences and clinical practice in one healthcare system, a system in which variation in the management of rectal cancer is evident [27].Targeted invitations to participate were sent via social media and email invitations from professional bodies (e.g. the ACPGBI).Exclusion criteria were being a trainee, not specializing in colorectal surgery and not currently practising in the UK.A minimum of 15 surgeons was considered necessary for data sufficiency, accounting for the study aims, breadth of the interview content and analytical methods [28].

Setting and data collection
Data collection was conducted remotely via Microsoft Teams audiorecording or in person during the ACPGBI Annual Meeting 2022.dropped out of the study, nor was any interview question unanswered.Participants were recruited until no new codes were generated after multiple consecutive interviews, suggesting data sufficiency was reached [29].

Data analysis and reporting
Interviews were recorded, transcribed verbatim and anonymized during the transcription process.Data were managed in NVivo qualitative data analysis software.Reflexive thematic analysis was performed following Braun and Clark's six-step framework [30].
This method enabled a nuanced understanding of the experiences and realities of individual participants to develop in-depth, comprehensive themes and gain new insights to achieve the primary and secondary aims of this study.CNB led the data coding and analysis.
Identified themes were reviewed and discussed within the team, until consensus was achieved.

Research team and reflexivity
The interviewer (CNB) was a female final year PhD researcher and general surgery trainee, with experience of conducting semistructured interviews and qualitative research.All participants were aware of the interviewer's position via the participant information sheet.The wider research team was multidisciplinary, including academics well-published in medical education with extensive experience of conducting qualitative research, as well as colorectal surgeons and an experienced colorectal research patient and public involvement representative.

Participant demographics
Seventeen consultant colorectal surgeons (eight female, nine male) participated.Eight surgeons identified as early career surgeons (i.e. had achieved certification of completion of training within the last 5 years), while nine had more than 5 years of consultant experience, with a spread of leadership experience at local, regional and national levels (including educational roles, unit leads, council positions on national associations).There was an even distribution of practice across university teaching hospitals and regionalized specialist centres.

Theme development
Two key themes with associated subthemes were identified from the data: (1) personal attributes influencing variation in decision-making and (2) the influence of anastomotic leaks on decision-making.
Quotations with pseudonyms are provided in tables to illustrate each theme (Tables S1 and S2).

Theme 1: Personal attributes influencing variation in decision-making
This theme contains three subthemes: (A) surgeon demographics Subtheme A: surgeon demographics Several participants discussed how demographic differences, specifically gender and experience, may account for variation in anastomotic decision-making and behaviour in the workplace.
Gender was considered an influencing factor by some participants (Surgeons 1 and 9).For example, female surgeons considered themselves more cautious when making difficult decisions compared with male colleagues.Some female surgeons also described making a more conscious effort to integrate themselves into the wider healthcare team to be listened to and respected.However, with increasing numbers of female surgeons in recent years, change in the culture of surgery was recognized and welcomed (Surgeons 10 and 12) (Table S1).
The degree of surgical experience also contributed to differences in decision-making.Experienced surgeons (those with more than 5 years of consultant practice) reflected on the changes seen in themselves throughout their career and described how they learned to self-manage stressful situations (Surgeons 6, 17 and 10).This included their experience of the consent process for rectal anastomoses, where careful preoperative discussion of patient preferences was identified as a method for reducing the guilt experienced by surgeons if a complication occurred (Surgeon 11).This may be of increasing importance in the Montgomery era of shared decisionmaking with patients and informed consent (where surgeons are required to explore all treatment options and risks with patients to allow patients to decide which to select).In contrast, early career consultants described feeling particularly vulnerable to the negative effects of postoperative complications and exerted caution in developing their independent practice learning curve (Surgeons 8 and 14) (Table S1).

Subtheme B: training experiences
The potentially positive role of fellowships to influence decisionmaking preferences was considered by some (Surgeons 7 and 12) and subspeciality practice was discussed by those working in tertiary centres (Surgeons 4, 11 and 16).Surgeons with subspeciality interests in inflammatory bowel disease (i.e.benign practice) described an increased tolerance for risk when making anastomotic decisions due to the condition of the patients they operate on, contrasting with advanced cancer practice surgeons who described themselves as risk-averse (Table S1), which may be due to witnessed effects of patients missing out on adjuvant treatment due to the experience of postoperative complications.

Subtheme C: individual influences on decision-making
Participants considered their individual thought processes and behaviour when making difficult decisions.Surgeons described how understanding their own personality could influence how they train others and interact with the wider healthcare team and patients (Surgeon 5).Surgeons described an inflexibility in the training styles of consultants, and it was suggested that better self-understanding could improve their ability to provide tailored mentorship of trainees.Surgeons acknowledged that their risktaking preferences and individual personalities may contribute to variation in decision-making in the highest-risk patients (Surgeons 7 and 17) (Table S1).

Theme 2: the impact of postoperative complications on the colorectal surgeon
This theme encompasses the psychological and physical responses of surgeons to major postoperative complications, including how long surgeons experience these effects for.Factors which influence surgeon behaviour, such as the hospital environment, team-working and methods of supporting surgeons, were apparent.

Subtheme A: psychological and physical effects of major complications on surgeons
While participants viewed the occurrence of an anastomotic leak as a professional inevitability (Surgeons 3 and 7), they remained emotionally affected when it occurred (Surgeons 8 and 11).Anastomotic leaks appear to have a significant and long-lasting impact (Surgeons 5 and 7), which relates to a sense of personal responsibility ('when your name is above the bed') and 'failure' (Surgeons 3 and 17).This is also manifest in sequelae such as insomnia and other health effects (Surgeons 5, 6, 7 and 15).However, there are situational aspects to this; for example, leaks occurring in the emergency setting appear to be easier to manage emotionally (Surgeons 3 and 4), perhaps because emergency patients present with higher-risk pathology and surgeons have less control over minimizing risk factors for complications.More guilt may also be experienced in the elective setting following the occurrence of major complications in asymptomatic bowel screening patients (Table S2).

Subtheme B: internal factors influencing individual responses
Surgeons considered how they initially responded to learning about adverse events.All described negative emotive reactions; however, developing an immediate 'action plan' was also considered important (Surgeons 6 and 8).Surgeons described the different ways in which they approach inpatients with postoperative complications.
For example, some were 'hands-on' whereas others were more evasive (Surgeons 5 and 8), which influenced how aggressive they were in the management of a confirmed leak (Surgeon 7).Early career surgeons were particularly focused on regularly checking blood tests and observations in the days following surgery to detect problems early (i.e.leak detection 'anxiety') (Surgeons 2 and 13), which appears to be less prominent in surgeons with more experience (Table S2).Surgeons were unclear if their individual personality traits could contribute to how they experience postoperative complications, for example if introverted surgeons experience anastomotic leaks differently from extraverted surgeons.Some surgeons described the importance of 'debriefing' with colleagues and partners (Surgeon 15), including the benefits of nonmedical confidantes (Surgeon 5).These effects may be mediated by functional working relationships with colleagues, including establishing team protocols about how best to manage postoperative complications (Surgeons 3 and 14).For example, having a 'consultant of the week' may mitigate biased decision-making when managing complications (Surgeon 11).It is also important to share these experiences with trainees and to normalize talking about the negative impact these may have (Surgeon 11) (Table S2).

Subtheme C: external factors influencing individual responses
Some surgeons identified fear of retribution from national audits of morbidity and mortality (M&M) as a factor influencing anastomotic decision-making and their emotional responses to complications (Surgeons 4 and 6).Scrutiny may also occur at local and regional levels, in the form of M&M meetings.However, the M&M meeting experiences of surgeons discussing their complications may change throughout their career (Surgeon 7).Undoubtedly, a supportive peer environment for surgeons is necessary for them to recover from a postoperative complication, which stems from the departmental and wider hospital culture (Surgeons 10 and 12) (Table S2).

Subtheme D: changes in practice following major complications
Some surgeons reported that they tried to remain conscious of decision-making following complications to ensure that only appropriate changes in practice occurred (i.e. when the complication was attributable to a technical reason) (Surgeons 7 and 15).However, it was considered by most participants that it would be 'human nature' to change practice following a major complication.The physical presence of having an inpatient who has suffered from a postoperative complication also exerts a significant weight on the minds of colorectal surgeons.To mitigate these effects, surgeons would prefer more 'choice' in their next operating list (Surgeon 10) (Table S2).Participants described a cautious approach to later decision-making, identifying potentially protective factors which may reduce the cognitive load and emotional burden of difficult decision-making.

DISCUSS ION
This is the first study to investigate the views of colorectal surgeons in respect of how individual factors such as gender, personality and risk-taking preferences may influence their surgical decision-making, their experience of complications and, subsequently, the effect on their next surgical decision.Surgeons feel a profound sense of guilt and personal responsibility following an anastomotic leak, and experience of a leak has a negative impact on their physical and mental wellbeing -even when it is not attributable to a technical error.Additionally, we found that these views are shaped throughout a surgeon's career, with differences in risk perceptions and behaviours between early career surgeons and more experienced surgeons.
On one level, our participants could rationalize that anastomotic leaks are professionally inevitable.However, on another, more emotional, level they saw them as evidence of personal 'failure', and this latter position is exacerbated by 'blame cultures' relating to hospital environments [31].Surgeons at all stages of their practice within this study described fear of 'being an outlier' in national outcomes reporting [32,33].However, early career female surgeons appeared to be particularly influenced by this perception.Some surgeons even described hesitancy in taking risks in cancer surgery compared with their other areas of clinical practice, as benign outcomes reporting is excluded from national datasets.
Our findings echo previous work where surgeons have been described as 'second casualties' following complications [16,17].Previous studies indicated that surgeons' personal recovery from adverse events was improved through peer discussion [34].
However, conversations around how surgeons experience and learn from complications still focus on the technical aspects, as evidenced by findings from this study and the wider literature [35].Ways must be found to ensure M&M meetings (or other methods of event debriefing) can be changed to encompass how people feel (e.g. the implementation of Schwartz rounds [36], which provide a structured forum for hospital staff to discuss and share their experiences of the emotional and social aspects of working in healthcare, with the focus on the challenges and rewards of providing care rather than specific patient-related issues) [36].Given that surgeons often have to make difficult decisions in stressful working environments [37], there may be lessons from other industries with similar demands.
For example, studies on firefighter welfare have demonstrated that enhancing the quality of interpersonal relationships and job control is imperative, and that encouraging problem-solving pondering [38] (focused thinking on potential ways to solve work problems, versus affective rumination which involves repetitive thinking of negative aspects of work) at the end of a shift is beneficial in helping employees 'switch off' when they go home [39].Similarities may be seen in the UK healthcare system and how surgeons process complications, particularly with the threat of litigation and implications for surgeon welfare [40].A shift towards problem-solving pondering in healthcare could potentially support surgeons and act as an adjunct to decision-making.
Given that there is evidence that personality traits can change in response to environmental exposures and life events [41], how major complications are experienced may also change throughout a surgeon's career.Longitudinal work would be helpful to examine this more closely, following surgeons as they gain experience.It may be particularly useful to also look at changes throughout careers given factors other than experience change.For example, older surgeons may find the management of anastomotic leaks particularly challenging due to increasing physical demands (e.g. of out of hours working), as well as increased emotional demands following an entire career of experiencing significant personal responsibility for patient welfare [42].Assessing the impact of psychological support following anastomotic leaks may be helpful to identify how best to support surgeons and encourage objective decision-making in similar, future situations [16].For example, the Resilience in Stressful Events (RISE) programme at Johns Hopkins Hospital [43], has been well-received by both peer responders and users.While this type of organization-led supportive intervention appears to be lacking in the UK, in 2020 the Royal College of Surgeons of England and Bournemouth University published 'Good Practice Guidelines' on supporting surgeons after adverse eventsa significant step [44].However, these recommendations are not yet standard practice, and at the time of writing the workforce remains dependent on informal peer support.While formal support programmes may be beneficial for participants, care must be taken not to focus on the implied resilience of individuals but rather to improve the mechanisms of organizations to support those individuals [45].

Strengths and limitations
Qualitative data provided a rich insight into surgeons' experiences of anastomotic leakage, experiences which cannot necessarily be quantified [46].Data sufficiency and analytical sufficiency were achieved through iterative data generation and analysis conducted throughout the study [29].In retrospect, our interview topic guide may have gained from more extensive piloting, but the research questions were developed after the team sought multiple perspectives from surgeons and nonsurgeons (including patient representation).We added to previous work in this area [16,17] by looking specifically at one speciality group with one common negative outcome in one healthcare system.
Our study is set in one country with a particular healthcare training and delivery model which may limit its generalizability to other contexts.However, the purpose of qualitative research is not statistical generalization and our focus is not unique to the context of this study.We call for further research on this important topic in other countries to allow comparison across contexts.
Even with a relatively small number of participants we have high information power due to a narrow study aim, a specific sample and good-quality data.Of course, as with any voluntary study using particular approaches to recruitment (e.g.social media), there may be an element of participant self-selection.Our participants were more or less equally distributed in terms of gender, unlike surgery which remains male-dominated at consultant level.We do not know if our participants' experiences or views are representative, but we plan to test this later using the data reported in this paper to inform the content of a survey tool which can be used to gain more views from a wider group of participants, including surgical trainees.

CON CLUS IONS
In the setting of difficult decision-making, colorectal surgeons consider anastomotic leaks to be personal 'failures'.This belief has implications for surgeons on a personal level and influences future anastomotic

CO N FLI C T O F I NTER E S T S TATEM ENT
The authors have no conflicts of interest to declare.

E TH I C S S TATEM ENT
Ethical approval was obtained from the University of Aberdeen School Ethics Review Board (SERB/2022/3/2268).

Field
notes were made contemporaneously to assist with later coding.Interviews lasted approximately 20-30 min.No participants What does this paper add to the literature?This qualitative study is the first to explore colorectal surgeons' perceptions of how personal attributes (e.g.training experiences, personality) may influence variation in anastomotic decision-making and the management of complications.This is necessary to identify methods for supporting surgeons and encourage open discussion, so that surgeons may learn from complications.
(e.g.gender, years of surgical experience), (B) training experiences (including subspeciality interest within colorectal surgery, e.g.advanced cancer, intestinal failure) and (C) individual influences on decision-making (e.g.cognitive factors such as personality, risktaking preferences).
decisions.The current study provided deep insight into colorectal surgeons' views of how they respond to an anastomotic leak and changes in perceptions with increasing experience.The importance of sharing experiences with colleagues and learning from one's own and others' experiences is necessary throughout one's career.Better understanding of how surgeons make difficult anastomotic decisions and how individual surgeons respond to and learn from complications may allow us to identify 'personalized' methods to support surgeons, for example the development of formal support programmes which are currently lacking.This will require a paradigm shift in surgical culture to normalize discussions around the psychological and physical sequelae of complications on individual surgeons and the development of novel interventions to better support surgeons.FU N D I N G I N FO R M ATI O N This work was kindly supported by Bowel Research UK and the Ileostomy and Internal Pouch Association.The funders had no influence in the design, delivery or interpretation of this study.