Surgeons' Expertise During Laparoscopic Cholecystectomy: An Expert-Novice Comparison

Surgeons' Expertise During Difficult Laparoscopic Cholecystectomy: An Expert-Novice Comparison Using Think Aloud Method Introduction: There are various methods to study expertise. In our preliminary study of Expert – Novice using think aloud method, we demonstrated the experts were notably different in their ability in cognition (comprehension of situation), mental image of future event and metacognition. In this follow-up study, we aimed to examine the differences between thought process of experts and novices surgeons while watching videos of intraoperative events during difficult laparoscopic cholecystectomies. Methods: A group of experienced and novice (general surgery residents Postgraduate Year 2) surgeons were individually shown a recording of two difficult laparoscopic cholecystectomies. A think-aloud method was used to capture their thought processes. Verbal reports were recorded during (concurrent) and after (retrospective reports) watching the video clips, transcribed verbatim and analyzed using the “protocol analysis” method. Ericsson and Simon’s model were used to develop coding schemes. The generalized estimating equation (GEE) model was used to analyze the verbalizations. Results: Twenty subjects (10 in each group) from two academic centers participated. The following coding schemes were developed from the verbal reports: perception, cognition (comprehension of the situation) and generated mental product (Ericsson and Simon); planning, metacognition, recall of previous experience/ knowledge and surgeon’s technical preferences. Overall, surgeons allocated majority of their cognitive focus on perception, cognition and mental product and planning. Experienced surgeons showed a significantly higher level of ability to comprehend the situation (cognition) and create a mental product in anticipation of future events. They also referred to their previous experience and personal preferences more often. They were more aware of their own thought process (metacognition) in evaluating the situation. In the rest of categories such as perception and coordination with team, the quantity of verbalizations was not significantly different between two groups. None of the verbalizations were suggestive of intuition as a mechanism for decision-making. The analysis of retrospective verbal reports showed a very similar pattern. Conclusions: This study validates the results of our previous pilot study and demonstrated the differences and similarities between surgeons with different levels of experience. It provides an insight to the thought process of novice and experienced surgeons during challenging cases laparoscopic cholecystectomy. These findings can be used to develop a model for training of surgical residents.