A Window Into the Mind: Preliminary Steps Towards the Development of a Hernia Management Assessment Tool for Surgeons

Mohammed AlRowais, MD, Amin Madani, MD, Yusuke Watanabe, MD, PhD, Mohammed Al Mahroos, MD, FRCSC, Elif Bilgic, Melina Vassiliou, MD, MEd, FRCSC, FACS. Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada

Introduction: Expert surgeons organize knowledge into mental representations they draw from when caring for patients.  The richness of this network is what defines expertise, and the complex integration of knowledge and skills is difficult to assess.  Inguinal hernias are common surgical problems, however, there are still gaps in the management of patients with hernias that could be addressed though education.  The purpose of this qualitative study was to explore the use of a clinical vignette, open-ended questions and videos as probes for uncovering expertise in the management of patients with inguinal hernias, and as an eventual methodology for the development of assessments. 

Methods: This was a qualitative study using semi-structured interviews based on a patient with an inguinal hernia including two short video clips of a laparoscopic TEP repair. The questions initially centered around management of the patient, and then participants were asked to comment about the videos, including recommendations they might have for the surgeon.  Participants included two attending surgeons who perform hernia surgery, and nine surgical residents (two-PGY1, two-PGY2, one-PGY3, two-PGY4, two-PGY5). All interviews were video-recorded and transcribed.

Results: Surgeons used language that was very specific, focused and practical.  They were quickly oriented to the operative field, identified anatomical planes and were concrete in their recommendations.  They demonstrated evidence of a robust cognitive structure also rich in readily accessible content. Senior residents used technical language that seemed directly out of a textbook. They were less oriented to the surgical field and when describing the technical aspects of the procedure, they used vague terms and general principles.  As a group they had a structured approach to the patient with clear gaps in content. Junior residents tended to focus more on the history, and detailed physical exam including surgical risks.  They were not able to orient to the procedure or make any suggestions, and their comments were focused mostly on safety.  They seemed to have an incomplete cognitive structure in addition to content lacunes.

Conclusion: This study identified clear differences in cognitive schemas for the management of inguinal hernias among surgeons.  This methodology may be used to create assessments of mental representations using expert patterns related to language, focus and the ability to orient to video clips.  These data may also provide insight into how surgeons acquire expertise at various stages of training and could be used to provide feedback to trainees or as part of the surgical curriculum. 

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