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Surgeon Workload in Colorectal Surgery: Perceived Drivers of Procedural Difficulty
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 2 0 ( 2 4 5 ) 5 7 e6 3
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Association for Academic Surgery
Surgeon Workload in Colorectal Surgery: Perceived Drivers of Procedural Difficulty Katherine E. Law, PhD,a,b Bethany R. Lowndes, PhD, MPH,a,c Scott R. Kelley, MD,d Renaldo C. Blocker, PhD,a,b David W. Larson, MD, MBA,d M. Susan Hallbeck, PhD,a,b,d,* and Heidi Nelson, MDd a
Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota c Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska d Department of Surgery, Mayo Clinic, Rochester, Minnesota b
article info
abstract
Article history:
Background: To understand how surgeon expectation of case difficulty relates to workload
Received 21 February 2019
for colon and rectal procedures and to identify possible surgeon-perceived drivers
Received in revised form
contributing to case difficulty.
11 June 2019
Materials and methods: For 3 mo, surgeons were asked to complete a modified NASA-Task
Accepted 20 June 2019
Load Index (NASA-TLX) questionnaire following each surgical case. Questions included
Available online xxx
items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 ¼ low, 20 ¼ high).
Keywords:
Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less
Human factors
difficult than expected). Surgeons also reported perceived drivers contributing to case ease or
Colorectal surgery
difficulty. Patient and procedural data were analyzed for procedures with completed surveys.
Cognitive demand
Results: Seven surgeons (three female) rated 122 procedures over the research period using
Physical demand
a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort
Expectation
(mean [M] ¼ 10.83, standard deviation [SD] ¼ 5.66) followed by mental demand (M ¼ 10.18,
Workload
SD ¼ 5.17), and physical demand (M ¼ 9.19, SD ¼ 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases. Conclusions: Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus. ª 2019 Elsevier Inc. All rights reserved.
* Corresponding author.Department of Health Sciences Research, Mayo Clinic, 200 First Street NW, Rochester, MN, 55905. Tel.: þ507 5387944; fax: þ507-538-7957. E-mail address: [email protected] (M.S. Hallbeck). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.06.084
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j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 2 0 ( 2 4 5 ) 5 7 e6 3
Introduction Surgeons’ perceptions of workload are most often associated with case load or surgical volume. This is typically defined by the required resources, number of operations performed, staffing requirements for procedures, or total operative time over a given period.1 In contrast, human factors researchers have relied on operator-based measures such as physiologic indicators or subjective ratings to assess workload.2 Much like nursing workload research,3 such resourced-based measures of surgeon workload are highly utilized because of their ease of accessibility from various data sources as well as ability for cross-organizational comparison. The downside to resourcebased measures of workload is that they do not always provide a clear sense of the work performed to accomplish successful outcomes. Subjective measures, on the other hand, can highlight surgeons’ pain points resultant from their work systemdcomplex surgical approaches or technique, equipment malfunction, or multifaceted issues surrounding patient anatomy or operative teamdand aid in intervention development. A prominent subjective measurement tool for evaluating workloaddNASA-Task Load Index (NASA-TLX)dwas developed in the late 1980s for aviation.4 It has since been applied in other domains such as the automotive industry5 and military settings.6,7 In the past decade, NASA-TLX has gained traction in healthcare and more specifically, surgery.8-13 The NASATLX instrument consists of six subscales that represent different aspects of workload: mental demand (MD), physical demand (PD), temporal demand (TD), effort (Ef), performance (Pe), and frustration (Fr). In surgery, it has raised concern over high workload experienced in the operating room14,15 and has been linked to declining surgical Pe.16 Recent research utilizing NASA-TLX demonstrated surgeons experience high levels of workload across multiple specialties.11 Most impactful of surgeons’ perceived workload was the role of case difficulty expectation, where cases that were more difficult than initially expected required significantly more workload than cases that matched expectation levels. While much of the research surrounding task expectation has focused on goal expectation, goal setting, or mental rehearsal in education and training,17,18 there is little understanding of what factors are associated with deviations from expected case difficulty in surgery. Building on previous work within the colorectal specialty,12 the aims of this study were to understand the role of case difficulty expectation with respect to workload for colon and rectal surgical procedures as well as identify possible surgeonperceived drivers contributing to deviation from case difficulty expectation.
Material and methods Setting and participants Data were collected at a large, nonprofit quaternary academic hospital between February and April 2018 for this Institutional Review Board approved study (#17-011258). Colorectal surgeons employed at the hospital that agreed to participate were orally
consented and asked to complete a modified NASA-TLX survey following each surgical case. The survey included questions on distractions, fatigue, procedural difficulty, and expectation in addition to the validated NASA-TLX questions following each surgical case. All but the expectation question were rated on a 20-point scale (0 ¼ low, 20 ¼ high). Expectation was rated on a 3point scale (i.e., more difficult than expected, as expected, less difficult than expected). Patient and procedural data were analyzed for procedures with completed surveys. Surgical approach was categorized as open, laparoscopic, or robotic.
Research protocol Surgeons agreeing to participate completed a demographic survey that included questions on his or her age, sex, height, weight, and surgical experience beyond residency. Following completion of the demographic survey, a study coordinator reviewed surgeons’ surgical schedules to identify cases in which volunteer participants were the operating surgeon for the case. The study coordinator then emailed out surveys for those cases, including information on the initial procedure listing, operating room, and case number of the day. Surveys were generated using Qualtrics (Version 2017, Provo, UT) and were administered via email using a secure link to surgeon participants on the day of their corresponding surgical case. Patient data for completed surveys were collected post hoc from the electronic health record. At the study institution, patients are able to opt out of institutional use of their medical data for research. Therefore, only information from patients that approved the use of their medical data for research purposes were utilized. Patient data collected from the electronic health record included body mass index (BMI), age, American Society of Anesthesiologists category, and procedural duration.
Workload and drivers questionnaire Participants were asked to complete a questionnaire within 24 h of each surgical procedure. The questionnaire consisted of the workload items from the original NASA-TLX11,12 but was modified to include additional questions targeted at the drivers contributing to procedural ease or difficulty. No alterations were made to the original NASA-TLX questionnaire. Workload questions from the previously validated NASA-TLX4 addressed MD, PD, TD, Pe, Ef, and Fr. Additional workload questions included one question on distraction from SURGTLX,13 one question fatigue adapted from Kuorinka et al.,19 and one question on procedural difficulty from Global Operative Assessment of Laparoscopic Skills.20 All workload questions were rated on a 20-point scale (0 ¼ low, 20 ¼ high). A question on variation from expected procedural difficulty was also included and was reported as “expected,” “less difficult than expected,” or “more difficult than expected.”11 As a result of findings in our previous work on colorectal workload,12 additional questions regarding drivers of workload were included. The driver questions included items on patient factors (e.g., anatomy, cancer, adhesions, previous surgery, and BMI), teaming (e.g., teamwork quality, team familiarity, multiple teams, and trainees), personal factors (e.g., on-call/post-call, other), and equipment (e.g., lack thereof,
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law et al workload drivers in colorectal surgery
malfunction). Checkboxes were used to facilitate easy and quick electronic survey completion; however, surgeons had the option to further elaborate in an open text box.21
Table 1 e Surgeon demographics. Demographics
Median (min, max) or n (%)
Age, y
Data analysis Data were stratified by general procedure type (i.e., anorectal, colectomy, proctectomy, or miscellaneous). Cases were also categorized by surgical approach (i.e., open, laparoscopic, robotically). Data analyses were conducted in SPSS, version 25.0 (IBM, Armonk, NY). Normally distributed variables were reported as means (Ms) with standard deviations (SDs). Nonparametric variables were reported as medians (Mdns) with interquartile ranges (IQRs). Analysis of variances were used to compare workload items and procedural difficulty by general procedure type, surgical approach, and procedural expectation. Tukey post-hoc tests identified differences among groups. P values < 0.05 were considered significant. Qualitative data (i.e., participant responses in the open text box) were thematically coded22 and counted along with participant-identified workload drivers.
Results Seven surgeons (3 female) rated 122 of 160 total procedures performed (76%) over the research period using the modified NASA-TLX survey. Participating surgeons completed surveys on 49 colectomies (40%), 24 proctectomies (20%), nine anorectal (7%), and 40 miscellaneous procedures (33%). Miscellaneous cases predominantly included procedures such as exploratory laparotomy and creation of ileostomy/colostomy. The majority of the cases were performed using open (n ¼ 76, 62%), followed by laparoscopic (n ¼ 34, 28%) and robot-assisted surgical (n ¼ 12, 10%) approaches. Participating surgeon case mix also varied. Only four of the surgeons performed robotic procedures (range ¼ 11% to 44% of participant cases); all surgeons performed open (Range ¼ 35% to 65% of participant cases) and laparoscopic procedures (Range ¼ 19% to 63% of participant cases) and at least one of each procedure type (Range ¼ 2% to 56% of participant cases). Surgeons’ experience post-residency ranged from 6 to 27 y (Table 1). Specifically, the Mdn reported experience for open and laparoscopic procedures was 15 y (IQR ¼ 6-27 and 6-17, respectively) for both. In contrast, the Mdn reported experience for robotic procedures was 3.5 y (IQR ¼ 3-6.25) for those surgeons performing robotassisted surgery. Surgeons were also categorized according to surgical experience postresidency into early career (0-5 y; n ¼ 1), mid-career (6-15 y; n ¼ 3), and established career (16 þ y; n ¼ 3). Participant cases were equally split among male and female patients, with 97% of patients identified as ASA II or III (Table 2).
Workload Surgeons reported a mean composite NASA-TLX score of 49.6 (SD ¼ 18.6) out of 100 overall. For the NASA-TLX subscales (out of a max of 20), Ef was the highest reported subscale (M ¼ 10.83, SD ¼ 5.66), followed by MD (M ¼ 10.18, SD ¼ 5.17) and PD (M ¼ 9.19, SD ¼ 5.60; Fig. 1A). Pe was the lowest rated
48 (41, 64)
Gender Female, n (%)
4 (57.1%)
Male, n (%)
3 (42.9%)
Height, inches
68 (65, 72)
Weight, pounds
153 (120, 175)
Surgical experience Open surgery, y
15 (5, 32)
Laparoscopic surgery, y
15 (5, 27)
Robotic surgery, y
3.5 (3, 10)
subscale (M ¼ 2.67, SD ¼ 2.71), meaning that participants generally felt they were successful in accomplishing everything they intended to do in the surgical procedure. Distraction (M ¼ 4.13, SD ¼ 3.63) was the second lowest rated subscale. Surgeon experience played a role in composite workload and certain subscales. The early career surgeon (i.e., 0-5 y of experience post residency) reported significantly lower composite workload than their established career counterparts (i.e., 16 þ y of experience post residency) (P ¼ 0.027). Similar trends were observed with perceived Pe, Fr, and distractions. The early career surgeon reported significantly less Fr and distractions and better perceived Pe than mid-career and established career surgeons (P < 0.05). There were no significant differences in perceived workload between mid-career and established career surgeons. Further analysis on the implications of surgical approach and patient factors on surgeon workload can be found elsewhere.11,12 Across all of the collected procedures, surgeons rated them moderately difficult (M ¼ 10.7, SD ¼ 5.6). There was no significant difference in procedural difficulty according to surgical experience or by surgical approach (Table 3); however, the percentage of cases rated more difficult (i.e., 10) varied. Approximately, half of open cases (n ¼ 41/76, 53.9%) received a difficulty rating of 10 or above, while 75% of robotic procedures (n ¼ 9/12) received the same rating. Procedural difficulty varied
Table 2 e Patient demographics. Demographics Age, y
Median (min, max) or n (%) 59.5 (19.8, 89.2)
Gender Female, n (%) Male, n (%) BMI
61 (50%) 61 (50%) 26.9 (14.3, 56.6)
ASA category I
1 (1%)
II
67 (55%)
III
52 (42%)
IV
2 (2%)
ASA ¼ American Society of Anesthesiologists.
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j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 2 0 ( 2 4 5 ) 5 7 e6 3
Fig. 1 e (A) Mean workload items across 122 cases; (B) Mean workload according to expectation of case difficulty. *P < 0.05.
significantly by procedure type (F(3,117) ¼ 6.0, P ¼ 0.001). Surgeons perceived proctectomies as significantly more difficult than anorectal (P ¼ 0.006) and miscellaneous (P ¼ 0.015) procedure types. Surgeons also perceived colectomies as significantly more difficult than anorectal procedures (P ¼ 0.021).
Expectation and perceptions of drivers Surgeons reported more than 50% of cases as expected (n ¼ 66, 54.1%), with 35.2% (n ¼ 43) rated as more difficult than expected. Neither patient age nor patient BMI significantly differed by expectation. In contrast, composite workload and all subscales but TD differed significantly according to expectation level (P < 0.05; Fig. 1B). Further analysis into the subscales that varied significantly by expectation level identified that when cases were more difficult than expected (n ¼ 43), MD, PD, Pe, Ef, Fr, distraction, and composite workload were significantly higher than both procedures rated as difficult as expected or rated less difficult than expected (P < 0.05). Procedural difficulty also varied significantly by expectation (P < 0.001). When procedures were more difficult than expected, they were rated significantly more difficult (M ¼ 14.4, SD ¼ 4.5) than procedures rated as difficult as
Table 3 e Procedural difficulty by surgical approach and procedure type.
Overall
Procedural difficulty, M (SD)
P value
10.7 (5.6)
e
Surgical approach Open
10.8 (5.4)
Laparoscopic
10.7 (5.8)
Robotic
14.0 (5.2)
>0.05
Procedure type
*
Colectomy
13.1 (5.6)
Proctectomy
11.8 (5.0)
Anorectal
6.2 (4.0)
Miscellaneous
9.0 (5.6)
P < 0.05.
0.001*
expected (M ¼ 9.29, SD ¼ 5.12; P < 0.001) or less difficult than expected (M ¼ 5.9, SD ¼ 4.2; P < 0.001). This may be driven by procedure type, as 75% of cases more difficult than expected were colectomy (n ¼ 22/43, 51.2%) or proctectomy (n ¼ 10/43, 23.3%) procedures. When surgeons perceived the case to be more difficult than expected, contributions with the operative team were most frequently cited (Table 4). The qualitative analysis approach yielded several examples to support this finding.22 For example, issues surrounding the operative team occurred as a result of a regular team member out on maternity leave, “I didn’t know the circulator or scrub nurse. My regular scrub nurse is on maternity leave.My circulating nurse was assigned to charge nurse today. I asked for the suction and the sucker wasn’t on the tubing, it hadn’t been set up, I asked for a marking pen and she handed me a scalpel.” Deviations in patient anatomy or larger body habitus were other common contributors to case difficulty. Examples of deviation occurred when anatomy differed from imaging, such as when a “tumor was adherent to local structures which was not seen on preoperative X-rays,” or as a result of adhesions. In contrast, surgeons noted good anatomy and body habitus along with support from surgical trainees as reasons why they perceived cases as easier than expected. For example one surgeon cited, “excellent anatomy, body habitus, simple tumor, and first time surgery,” as reasons for a case that was less difficult than expected.
Discussion Seven colon and rectal attending surgeons participated in this descriptive study completing 122 surveys to quantify their perceived workload. Most participants were mid-career level surgeons and beyond with 15 or more years of experience post residency for open and laparoscopic procedures. As the study was performed with a real world surgical specialty, the case mix of surgeons varied. All participants performed open and laparoscopic procedures and a subset of participants performed robotic procedures. Patients were generally older, overweight, and classified as American Society of Anesthesiologists Class II or III. As this study aimed to analyze workload with respect to surgeon expectation of case difficulty as well as identify perceived drivers of procedural difficulty, the data
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Table 4 e Frequency (n) of perceived contributors to case difficulty. Contributors
Less difficult than expected
As expected
More difficult than expected
Operative team (e.g., teamwork, multiple teams, trainees)
4
11
10
Anatomy and body habitus (e.g., adhesions, obesity, deviation from imaging)
7
6
9
On/post call
2
3
4
Patient diagnosis and history (e.g., cancer, previous surgery, first time surgery)
1
0
4
Patient/family expectations
1
7
2
Equipment (e.g., availability, malfunction)
0
0
1
represent a cross-section of procedures and surgical approaches that surgeons performed over a 3 mo period. Results from this study showed procedural difficulty varied significantly by procedure type, with both colectomy and proctectomy procedures rated highest. This demonstrates how the procedural difficulty item incorporated in the modified NASA-TLX instrumentdoriginally developed for laparoscopic procedures20dcan also reliably differentiate procedures that are performed using various surgical approaches. Surgeons more often experience challenges such as visceral obesity, adhesions, and a narrow pelvic working space during colectomy and proctectomy procedures that are not often experienced during anorectal or other procedures such as colostomy or ileostomy creation. Furthermore, previous work has shown surgeon workload during proctectomy and colectomy procedures commonly exceed the midpoint threshold (i.e., 50 out of 100),12 which may be indicative of the overall difficulty level identified by participants in the current study. Surgeons however did not report a significant difference in procedural difficulty according to their experience level. Yet, a relationship between workload and surgeon experience was identified, where early career surgeons reported lower perceived composite workload along with lower distractions, Frs, and better subjective Pe than establishedcareer surgeons. It is not yet clear what contributed to these observed differences. Many factors may be at play, such as varying patient factors or which surgical approach was utilized.12 Owing to the nature of conducting research in a realworld surgical practice, it was not possible to match cases according to such factors. Unexpectedly, surgeons reported 35% of their cases as more difficult than expected. Previous research has shown only 22% of cases across multiple specialties were more difficult than expected,11 indicating a 168% increase for colorectal procedures specifically. This both highlights an area to target future intervention opportunities, as well as validates the purpose of this study. Possible interventions to reduce the likelihood of cases being more difficult than expected could include increased use of imaging and team briefings. Scheduling time for surgeons and residents to review imaging and explicitly identifying potential areas of difficulty during briefings could help create shared mental models of the procedure and get team members thinking proactively about what they can do individually to make the case go as planned. By taking the time for such interventions before surgical cases and anticipating what may contribute to increased difficulty, it could address
issues that arise intraoperatively that lead to case expectation deviation. As we anticipated, composite NASA-TLX workload and most subscales differed significantly according to surgeon expectation of procedural difficulty. The study performed by Lowndes et al. (2018)11 demonstrated all subscales, but distractions were significantly higher when a case was more difficult than expected. Findings from the current study identified that MD, PD, Pe, Ef, Fr, distraction, and composite workload were significantly higher when cases were considered more difficult than expected than procedures rated both as difficult as expected or rated less difficult than expected. This may be an indication that colorectal procedures involve more distractions or that colorectal surgeons maintain similar levels of TD regardless of expectation level. However, this variation may also be a result of comparing results from multiple specialties to one specific specialty. Regardless, higher workload levels could have negative implications for Pe. For example, aviation research has linked higher workload to operator errors.23 Higher mental workload was also associated with more inadvertent injuries to adjacent structure during laparoscopic tasks as well as poorer suturing Pe.16 Surgeons identified multiple drivers contributing to the 35% of cases with higher than unexpected difficulty. Most frequently identified drivers of this difficulty were patient anatomy and body habitus as well as the operative team contributing to cases that were more difficult than expected. Issues surrounding teamwork quality or team familiarity have been linked to decreased quality of intraoperative care24 and errors,25 which could lead to increased procedure difficulty levels. Furthermore, incorporating resident training can add another layer of complexity or difficulty.26 Participants in this study commonly identified patient obesity when describing problems with patient anatomy or body habitus, as well as anatomical deviations not identified in preoperative imaging. With the rise of obesity from 12% to 49%,27 surgeons should expect to see an increased prevalence in their patient population as well. Identifying resources or processes that will better accommodate this patient characteristicdsuch as positioning and equipmentdbefore surgery could aid in reducing the burden experienced by surgeons. While it is unclear the types of imaging surgeons performed and how much time was spent reviewing patient files before surgery, such information could provide insight into potential root causes of why this occurred. It is important to note that while these factors were most commonly identified as drivers contributing to increased procedural difficulty, they were also factors that
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surgeons noted as reasons why they perceived cases as easier than expected. For example, while surgeons identified obesity as a contributor to difficult cases, they also attributed ideal body habitus as a contributor to less difficult cases.
Limitations Limitations are inherent to all research. This was a study of real-world cases performed by a single specialty at a quaternary care academic institution; therefore, there is heterogeneity in the patient data and case mixes of participating surgeons, which may not represent the frequency or variety of cases performed at other institutions. The study institution also performs highly complex procedures, so further studies are needed that explore workload and potential drivers of procedural difficulty across academic and nonacademic institutions as well as large and small institutions. While this study focused on surgeon-perceived contributors to deviation from case difficulty expectation in colorectal surgery, this cannot be generalized to other specialties and findings should be validated by objective means.
Conclusion This was the first study of its kind to identify surgeonperceived drivers of deviations from case difficulty expectation. Surgeons reported more than one-third of their cases as being more difficult than expected before the surgical procedure, which significantly increased their perceived workload including MD and PD and Ef. During cases that were more difficult than anticipated, surgeons most frequently attributed this to operative team characteristics as well as issues in patient anatomy and body habitus, which was not consistent with the patient data. By examining surgeon workload and perceived drivers of procedural difficulty, it has highlighted potential opportunities for intervention that could eliminate deviations from expectation and mitigate unnecessarily high workload.
Author contributions M.S.H. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. K.E.L. contributed to study design, acquisition of data, analysis and interpretation of data, article drafting, and critical revision. B.R.L. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision. S.R.K. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision. R.C.B. contributed to study design, acquisition of data, and critical revision. D.W.L. contributed to study design, acquisition of data, and critical revision. M.S.H. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision. H.N. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision.
Disclosure The authors have no financial or personal relationships with other people or organizations that could potentially and inappropriately influence (bias) this study and conclusions.
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Association for Academic Surgery
Surgeon Workload in Colorectal Surgery: Perceived Drivers of Procedural Difficulty Katherine E. Law, PhD,a,b Bethany R. Lowndes, PhD, MPH,a,c Scott R. Kelley, MD,d Renaldo C. Blocker, PhD,a,b David W. Larson, MD, MBA,d M. Susan Hallbeck, PhD,a,b,d,* and Heidi Nelson, MDd a
Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota c Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska d Department of Surgery, Mayo Clinic, Rochester, Minnesota b
article info
abstract
Article history:
Background: To understand how surgeon expectation of case difficulty relates to workload
Received 21 February 2019
for colon and rectal procedures and to identify possible surgeon-perceived drivers
Received in revised form
contributing to case difficulty.
11 June 2019
Materials and methods: For 3 mo, surgeons were asked to complete a modified NASA-Task
Accepted 20 June 2019
Load Index (NASA-TLX) questionnaire following each surgical case. Questions included
Available online xxx
items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 ¼ low, 20 ¼ high).
Keywords:
Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less
Human factors
difficult than expected). Surgeons also reported perceived drivers contributing to case ease or
Colorectal surgery
difficulty. Patient and procedural data were analyzed for procedures with completed surveys.
Cognitive demand
Results: Seven surgeons (three female) rated 122 procedures over the research period using
Physical demand
a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort
Expectation
(mean [M] ¼ 10.83, standard deviation [SD] ¼ 5.66) followed by mental demand (M ¼ 10.18,
Workload
SD ¼ 5.17), and physical demand (M ¼ 9.19, SD ¼ 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases. Conclusions: Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus. ª 2019 Elsevier Inc. All rights reserved.
* Corresponding author.Department of Health Sciences Research, Mayo Clinic, 200 First Street NW, Rochester, MN, 55905. Tel.: þ507 5387944; fax: þ507-538-7957. E-mail address: [email protected] (M.S. Hallbeck). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.06.084
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Introduction Surgeons’ perceptions of workload are most often associated with case load or surgical volume. This is typically defined by the required resources, number of operations performed, staffing requirements for procedures, or total operative time over a given period.1 In contrast, human factors researchers have relied on operator-based measures such as physiologic indicators or subjective ratings to assess workload.2 Much like nursing workload research,3 such resourced-based measures of surgeon workload are highly utilized because of their ease of accessibility from various data sources as well as ability for cross-organizational comparison. The downside to resourcebased measures of workload is that they do not always provide a clear sense of the work performed to accomplish successful outcomes. Subjective measures, on the other hand, can highlight surgeons’ pain points resultant from their work systemdcomplex surgical approaches or technique, equipment malfunction, or multifaceted issues surrounding patient anatomy or operative teamdand aid in intervention development. A prominent subjective measurement tool for evaluating workloaddNASA-Task Load Index (NASA-TLX)dwas developed in the late 1980s for aviation.4 It has since been applied in other domains such as the automotive industry5 and military settings.6,7 In the past decade, NASA-TLX has gained traction in healthcare and more specifically, surgery.8-13 The NASATLX instrument consists of six subscales that represent different aspects of workload: mental demand (MD), physical demand (PD), temporal demand (TD), effort (Ef), performance (Pe), and frustration (Fr). In surgery, it has raised concern over high workload experienced in the operating room14,15 and has been linked to declining surgical Pe.16 Recent research utilizing NASA-TLX demonstrated surgeons experience high levels of workload across multiple specialties.11 Most impactful of surgeons’ perceived workload was the role of case difficulty expectation, where cases that were more difficult than initially expected required significantly more workload than cases that matched expectation levels. While much of the research surrounding task expectation has focused on goal expectation, goal setting, or mental rehearsal in education and training,17,18 there is little understanding of what factors are associated with deviations from expected case difficulty in surgery. Building on previous work within the colorectal specialty,12 the aims of this study were to understand the role of case difficulty expectation with respect to workload for colon and rectal surgical procedures as well as identify possible surgeonperceived drivers contributing to deviation from case difficulty expectation.
Material and methods Setting and participants Data were collected at a large, nonprofit quaternary academic hospital between February and April 2018 for this Institutional Review Board approved study (#17-011258). Colorectal surgeons employed at the hospital that agreed to participate were orally
consented and asked to complete a modified NASA-TLX survey following each surgical case. The survey included questions on distractions, fatigue, procedural difficulty, and expectation in addition to the validated NASA-TLX questions following each surgical case. All but the expectation question were rated on a 20-point scale (0 ¼ low, 20 ¼ high). Expectation was rated on a 3point scale (i.e., more difficult than expected, as expected, less difficult than expected). Patient and procedural data were analyzed for procedures with completed surveys. Surgical approach was categorized as open, laparoscopic, or robotic.
Research protocol Surgeons agreeing to participate completed a demographic survey that included questions on his or her age, sex, height, weight, and surgical experience beyond residency. Following completion of the demographic survey, a study coordinator reviewed surgeons’ surgical schedules to identify cases in which volunteer participants were the operating surgeon for the case. The study coordinator then emailed out surveys for those cases, including information on the initial procedure listing, operating room, and case number of the day. Surveys were generated using Qualtrics (Version 2017, Provo, UT) and were administered via email using a secure link to surgeon participants on the day of their corresponding surgical case. Patient data for completed surveys were collected post hoc from the electronic health record. At the study institution, patients are able to opt out of institutional use of their medical data for research. Therefore, only information from patients that approved the use of their medical data for research purposes were utilized. Patient data collected from the electronic health record included body mass index (BMI), age, American Society of Anesthesiologists category, and procedural duration.
Workload and drivers questionnaire Participants were asked to complete a questionnaire within 24 h of each surgical procedure. The questionnaire consisted of the workload items from the original NASA-TLX11,12 but was modified to include additional questions targeted at the drivers contributing to procedural ease or difficulty. No alterations were made to the original NASA-TLX questionnaire. Workload questions from the previously validated NASA-TLX4 addressed MD, PD, TD, Pe, Ef, and Fr. Additional workload questions included one question on distraction from SURGTLX,13 one question fatigue adapted from Kuorinka et al.,19 and one question on procedural difficulty from Global Operative Assessment of Laparoscopic Skills.20 All workload questions were rated on a 20-point scale (0 ¼ low, 20 ¼ high). A question on variation from expected procedural difficulty was also included and was reported as “expected,” “less difficult than expected,” or “more difficult than expected.”11 As a result of findings in our previous work on colorectal workload,12 additional questions regarding drivers of workload were included. The driver questions included items on patient factors (e.g., anatomy, cancer, adhesions, previous surgery, and BMI), teaming (e.g., teamwork quality, team familiarity, multiple teams, and trainees), personal factors (e.g., on-call/post-call, other), and equipment (e.g., lack thereof,
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malfunction). Checkboxes were used to facilitate easy and quick electronic survey completion; however, surgeons had the option to further elaborate in an open text box.21
Table 1 e Surgeon demographics. Demographics
Median (min, max) or n (%)
Age, y
Data analysis Data were stratified by general procedure type (i.e., anorectal, colectomy, proctectomy, or miscellaneous). Cases were also categorized by surgical approach (i.e., open, laparoscopic, robotically). Data analyses were conducted in SPSS, version 25.0 (IBM, Armonk, NY). Normally distributed variables were reported as means (Ms) with standard deviations (SDs). Nonparametric variables were reported as medians (Mdns) with interquartile ranges (IQRs). Analysis of variances were used to compare workload items and procedural difficulty by general procedure type, surgical approach, and procedural expectation. Tukey post-hoc tests identified differences among groups. P values < 0.05 were considered significant. Qualitative data (i.e., participant responses in the open text box) were thematically coded22 and counted along with participant-identified workload drivers.
Results Seven surgeons (3 female) rated 122 of 160 total procedures performed (76%) over the research period using the modified NASA-TLX survey. Participating surgeons completed surveys on 49 colectomies (40%), 24 proctectomies (20%), nine anorectal (7%), and 40 miscellaneous procedures (33%). Miscellaneous cases predominantly included procedures such as exploratory laparotomy and creation of ileostomy/colostomy. The majority of the cases were performed using open (n ¼ 76, 62%), followed by laparoscopic (n ¼ 34, 28%) and robot-assisted surgical (n ¼ 12, 10%) approaches. Participating surgeon case mix also varied. Only four of the surgeons performed robotic procedures (range ¼ 11% to 44% of participant cases); all surgeons performed open (Range ¼ 35% to 65% of participant cases) and laparoscopic procedures (Range ¼ 19% to 63% of participant cases) and at least one of each procedure type (Range ¼ 2% to 56% of participant cases). Surgeons’ experience post-residency ranged from 6 to 27 y (Table 1). Specifically, the Mdn reported experience for open and laparoscopic procedures was 15 y (IQR ¼ 6-27 and 6-17, respectively) for both. In contrast, the Mdn reported experience for robotic procedures was 3.5 y (IQR ¼ 3-6.25) for those surgeons performing robotassisted surgery. Surgeons were also categorized according to surgical experience postresidency into early career (0-5 y; n ¼ 1), mid-career (6-15 y; n ¼ 3), and established career (16 þ y; n ¼ 3). Participant cases were equally split among male and female patients, with 97% of patients identified as ASA II or III (Table 2).
Workload Surgeons reported a mean composite NASA-TLX score of 49.6 (SD ¼ 18.6) out of 100 overall. For the NASA-TLX subscales (out of a max of 20), Ef was the highest reported subscale (M ¼ 10.83, SD ¼ 5.66), followed by MD (M ¼ 10.18, SD ¼ 5.17) and PD (M ¼ 9.19, SD ¼ 5.60; Fig. 1A). Pe was the lowest rated
48 (41, 64)
Gender Female, n (%)
4 (57.1%)
Male, n (%)
3 (42.9%)
Height, inches
68 (65, 72)
Weight, pounds
153 (120, 175)
Surgical experience Open surgery, y
15 (5, 32)
Laparoscopic surgery, y
15 (5, 27)
Robotic surgery, y
3.5 (3, 10)
subscale (M ¼ 2.67, SD ¼ 2.71), meaning that participants generally felt they were successful in accomplishing everything they intended to do in the surgical procedure. Distraction (M ¼ 4.13, SD ¼ 3.63) was the second lowest rated subscale. Surgeon experience played a role in composite workload and certain subscales. The early career surgeon (i.e., 0-5 y of experience post residency) reported significantly lower composite workload than their established career counterparts (i.e., 16 þ y of experience post residency) (P ¼ 0.027). Similar trends were observed with perceived Pe, Fr, and distractions. The early career surgeon reported significantly less Fr and distractions and better perceived Pe than mid-career and established career surgeons (P < 0.05). There were no significant differences in perceived workload between mid-career and established career surgeons. Further analysis on the implications of surgical approach and patient factors on surgeon workload can be found elsewhere.11,12 Across all of the collected procedures, surgeons rated them moderately difficult (M ¼ 10.7, SD ¼ 5.6). There was no significant difference in procedural difficulty according to surgical experience or by surgical approach (Table 3); however, the percentage of cases rated more difficult (i.e., 10) varied. Approximately, half of open cases (n ¼ 41/76, 53.9%) received a difficulty rating of 10 or above, while 75% of robotic procedures (n ¼ 9/12) received the same rating. Procedural difficulty varied
Table 2 e Patient demographics. Demographics Age, y
Median (min, max) or n (%) 59.5 (19.8, 89.2)
Gender Female, n (%) Male, n (%) BMI
61 (50%) 61 (50%) 26.9 (14.3, 56.6)
ASA category I
1 (1%)
II
67 (55%)
III
52 (42%)
IV
2 (2%)
ASA ¼ American Society of Anesthesiologists.
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Fig. 1 e (A) Mean workload items across 122 cases; (B) Mean workload according to expectation of case difficulty. *P < 0.05.
significantly by procedure type (F(3,117) ¼ 6.0, P ¼ 0.001). Surgeons perceived proctectomies as significantly more difficult than anorectal (P ¼ 0.006) and miscellaneous (P ¼ 0.015) procedure types. Surgeons also perceived colectomies as significantly more difficult than anorectal procedures (P ¼ 0.021).
Expectation and perceptions of drivers Surgeons reported more than 50% of cases as expected (n ¼ 66, 54.1%), with 35.2% (n ¼ 43) rated as more difficult than expected. Neither patient age nor patient BMI significantly differed by expectation. In contrast, composite workload and all subscales but TD differed significantly according to expectation level (P < 0.05; Fig. 1B). Further analysis into the subscales that varied significantly by expectation level identified that when cases were more difficult than expected (n ¼ 43), MD, PD, Pe, Ef, Fr, distraction, and composite workload were significantly higher than both procedures rated as difficult as expected or rated less difficult than expected (P < 0.05). Procedural difficulty also varied significantly by expectation (P < 0.001). When procedures were more difficult than expected, they were rated significantly more difficult (M ¼ 14.4, SD ¼ 4.5) than procedures rated as difficult as
Table 3 e Procedural difficulty by surgical approach and procedure type.
Overall
Procedural difficulty, M (SD)
P value
10.7 (5.6)
e
Surgical approach Open
10.8 (5.4)
Laparoscopic
10.7 (5.8)
Robotic
14.0 (5.2)
>0.05
Procedure type
*
Colectomy
13.1 (5.6)
Proctectomy
11.8 (5.0)
Anorectal
6.2 (4.0)
Miscellaneous
9.0 (5.6)
P < 0.05.
0.001*
expected (M ¼ 9.29, SD ¼ 5.12; P < 0.001) or less difficult than expected (M ¼ 5.9, SD ¼ 4.2; P < 0.001). This may be driven by procedure type, as 75% of cases more difficult than expected were colectomy (n ¼ 22/43, 51.2%) or proctectomy (n ¼ 10/43, 23.3%) procedures. When surgeons perceived the case to be more difficult than expected, contributions with the operative team were most frequently cited (Table 4). The qualitative analysis approach yielded several examples to support this finding.22 For example, issues surrounding the operative team occurred as a result of a regular team member out on maternity leave, “I didn’t know the circulator or scrub nurse. My regular scrub nurse is on maternity leave.My circulating nurse was assigned to charge nurse today. I asked for the suction and the sucker wasn’t on the tubing, it hadn’t been set up, I asked for a marking pen and she handed me a scalpel.” Deviations in patient anatomy or larger body habitus were other common contributors to case difficulty. Examples of deviation occurred when anatomy differed from imaging, such as when a “tumor was adherent to local structures which was not seen on preoperative X-rays,” or as a result of adhesions. In contrast, surgeons noted good anatomy and body habitus along with support from surgical trainees as reasons why they perceived cases as easier than expected. For example one surgeon cited, “excellent anatomy, body habitus, simple tumor, and first time surgery,” as reasons for a case that was less difficult than expected.
Discussion Seven colon and rectal attending surgeons participated in this descriptive study completing 122 surveys to quantify their perceived workload. Most participants were mid-career level surgeons and beyond with 15 or more years of experience post residency for open and laparoscopic procedures. As the study was performed with a real world surgical specialty, the case mix of surgeons varied. All participants performed open and laparoscopic procedures and a subset of participants performed robotic procedures. Patients were generally older, overweight, and classified as American Society of Anesthesiologists Class II or III. As this study aimed to analyze workload with respect to surgeon expectation of case difficulty as well as identify perceived drivers of procedural difficulty, the data
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Table 4 e Frequency (n) of perceived contributors to case difficulty. Contributors
Less difficult than expected
As expected
More difficult than expected
Operative team (e.g., teamwork, multiple teams, trainees)
4
11
10
Anatomy and body habitus (e.g., adhesions, obesity, deviation from imaging)
7
6
9
On/post call
2
3
4
Patient diagnosis and history (e.g., cancer, previous surgery, first time surgery)
1
0
4
Patient/family expectations
1
7
2
Equipment (e.g., availability, malfunction)
0
0
1
represent a cross-section of procedures and surgical approaches that surgeons performed over a 3 mo period. Results from this study showed procedural difficulty varied significantly by procedure type, with both colectomy and proctectomy procedures rated highest. This demonstrates how the procedural difficulty item incorporated in the modified NASA-TLX instrumentdoriginally developed for laparoscopic procedures20dcan also reliably differentiate procedures that are performed using various surgical approaches. Surgeons more often experience challenges such as visceral obesity, adhesions, and a narrow pelvic working space during colectomy and proctectomy procedures that are not often experienced during anorectal or other procedures such as colostomy or ileostomy creation. Furthermore, previous work has shown surgeon workload during proctectomy and colectomy procedures commonly exceed the midpoint threshold (i.e., 50 out of 100),12 which may be indicative of the overall difficulty level identified by participants in the current study. Surgeons however did not report a significant difference in procedural difficulty according to their experience level. Yet, a relationship between workload and surgeon experience was identified, where early career surgeons reported lower perceived composite workload along with lower distractions, Frs, and better subjective Pe than establishedcareer surgeons. It is not yet clear what contributed to these observed differences. Many factors may be at play, such as varying patient factors or which surgical approach was utilized.12 Owing to the nature of conducting research in a realworld surgical practice, it was not possible to match cases according to such factors. Unexpectedly, surgeons reported 35% of their cases as more difficult than expected. Previous research has shown only 22% of cases across multiple specialties were more difficult than expected,11 indicating a 168% increase for colorectal procedures specifically. This both highlights an area to target future intervention opportunities, as well as validates the purpose of this study. Possible interventions to reduce the likelihood of cases being more difficult than expected could include increased use of imaging and team briefings. Scheduling time for surgeons and residents to review imaging and explicitly identifying potential areas of difficulty during briefings could help create shared mental models of the procedure and get team members thinking proactively about what they can do individually to make the case go as planned. By taking the time for such interventions before surgical cases and anticipating what may contribute to increased difficulty, it could address
issues that arise intraoperatively that lead to case expectation deviation. As we anticipated, composite NASA-TLX workload and most subscales differed significantly according to surgeon expectation of procedural difficulty. The study performed by Lowndes et al. (2018)11 demonstrated all subscales, but distractions were significantly higher when a case was more difficult than expected. Findings from the current study identified that MD, PD, Pe, Ef, Fr, distraction, and composite workload were significantly higher when cases were considered more difficult than expected than procedures rated both as difficult as expected or rated less difficult than expected. This may be an indication that colorectal procedures involve more distractions or that colorectal surgeons maintain similar levels of TD regardless of expectation level. However, this variation may also be a result of comparing results from multiple specialties to one specific specialty. Regardless, higher workload levels could have negative implications for Pe. For example, aviation research has linked higher workload to operator errors.23 Higher mental workload was also associated with more inadvertent injuries to adjacent structure during laparoscopic tasks as well as poorer suturing Pe.16 Surgeons identified multiple drivers contributing to the 35% of cases with higher than unexpected difficulty. Most frequently identified drivers of this difficulty were patient anatomy and body habitus as well as the operative team contributing to cases that were more difficult than expected. Issues surrounding teamwork quality or team familiarity have been linked to decreased quality of intraoperative care24 and errors,25 which could lead to increased procedure difficulty levels. Furthermore, incorporating resident training can add another layer of complexity or difficulty.26 Participants in this study commonly identified patient obesity when describing problems with patient anatomy or body habitus, as well as anatomical deviations not identified in preoperative imaging. With the rise of obesity from 12% to 49%,27 surgeons should expect to see an increased prevalence in their patient population as well. Identifying resources or processes that will better accommodate this patient characteristicdsuch as positioning and equipmentdbefore surgery could aid in reducing the burden experienced by surgeons. While it is unclear the types of imaging surgeons performed and how much time was spent reviewing patient files before surgery, such information could provide insight into potential root causes of why this occurred. It is important to note that while these factors were most commonly identified as drivers contributing to increased procedural difficulty, they were also factors that
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surgeons noted as reasons why they perceived cases as easier than expected. For example, while surgeons identified obesity as a contributor to difficult cases, they also attributed ideal body habitus as a contributor to less difficult cases.
Limitations Limitations are inherent to all research. This was a study of real-world cases performed by a single specialty at a quaternary care academic institution; therefore, there is heterogeneity in the patient data and case mixes of participating surgeons, which may not represent the frequency or variety of cases performed at other institutions. The study institution also performs highly complex procedures, so further studies are needed that explore workload and potential drivers of procedural difficulty across academic and nonacademic institutions as well as large and small institutions. While this study focused on surgeon-perceived contributors to deviation from case difficulty expectation in colorectal surgery, this cannot be generalized to other specialties and findings should be validated by objective means.
Conclusion This was the first study of its kind to identify surgeonperceived drivers of deviations from case difficulty expectation. Surgeons reported more than one-third of their cases as being more difficult than expected before the surgical procedure, which significantly increased their perceived workload including MD and PD and Ef. During cases that were more difficult than anticipated, surgeons most frequently attributed this to operative team characteristics as well as issues in patient anatomy and body habitus, which was not consistent with the patient data. By examining surgeon workload and perceived drivers of procedural difficulty, it has highlighted potential opportunities for intervention that could eliminate deviations from expectation and mitigate unnecessarily high workload.
Author contributions M.S.H. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. K.E.L. contributed to study design, acquisition of data, analysis and interpretation of data, article drafting, and critical revision. B.R.L. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision. S.R.K. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision. R.C.B. contributed to study design, acquisition of data, and critical revision. D.W.L. contributed to study design, acquisition of data, and critical revision. M.S.H. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision. H.N. contributed to study design, acquisition of data, analysis and interpretation of data, and critical revision.
Disclosure The authors have no financial or personal relationships with other people or organizations that could potentially and inappropriately influence (bias) this study and conclusions.
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