Review
Surgeons and cognitive processes
J. C. Hall, C. Ellis and J. Hamdorf
Department of Surgery, University of Western Australia, Perth, Australia
Correspondence to: Professor J. C. Hall, University Department of Surgery, Royal Perth Hospital, Wellington Street, Perth, Western Australia 6000,
Australia (e-mail: jchall@cyllene.uwa.edu.au)
Background: The surgical mind is geared to make important decisions and perform highly skilled tasks.
The aim of this review is to explore the cognitive processes that link these actions.
Methods: The core of this review is derived from a literature search of a computer database (Medline).
Results and conclusion: The surgical image is one of action. However, the effective performance of
surgery requires more than mere manual dexterity and it is evident that competent surgeons exhibit the
cognitive traits that are held by all experts. The changes that are occurring in surgery indicate a need to
place greater emphasis on the cognitive processes that underpin the practice of surgery. It is important
that surgeons do not become victims of their own cult image.
Paper accepted 22 August 2002
Published online 29 November 2002 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4020
Introduction
Surgical competence combines the intellectual exercise of
decision making with the ability to perform mechanical
tasks1 . It is useful to explore the nature of the processes
that link these areas of endeavour. In the past they have
been treated as separate entities, and it has been difficult to
dissect out the inferences and consequences of phrases such
as ‘technical skill is a double edged weapon’. Little attention
has been paid to the cognitive processes that underpin
surgical competence. In this context, the term cognitive
processes relates to the ability to acquire knowledge by the
use of reasoning, intuition or perception (L. cognoscere, to
get to know).
This review commences with a discussion of the surgical
frame of mind and then reflects on how the general traits
of experts can be aligned with the characteristics of highly
effective surgeons. Finally, there is a discussion of the
implications that these issues have for surgical education.
The surgical mentality
This section explores the mindset of surgeons and how they
are perceived by others. Much of the ‘evidence’ is anecdotal,
but nevertheless it is an important issue. Behaviour and
learning patterns are influenced by perceptions of what it
means to be a surgeon.
Copyright  2002 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
The image
In 1963, Sir Robert Platt commented that ‘Surgeons, I
suspect, see themselves in a setting of glamour, conquering
disease by the bold strokes of sheer technical skill.
Physicians quietly remember that they were educated
gentlemen, centuries ago, when surgeons and apothecaries
were tradesmen’2 . Along the same lines, it has been said that
‘Surgeons are apostrophized as simple souls, men of action
who look for straightforward solutions’3 . However, as
Moore has commented ‘Anyone could bleed, give cinchona
bark or mercurials, or ‘‘puke, purge, and perspire’’, but only
a few could amputate a painful compound fracture quickly,
safely, and with a reasonable occurrence of survival’4 .
Surgeons sometimes embrace the hypothesis that they
are ‘men of action’ and use it as an opportunity to disparage
physicians for being too slow to act. According to Harken5
‘We surgeons tend to dive into the swamp and look
around for alligators while our internist colleagues analyze
the swamp water for its osmolality, acidity, and nutrient
content to see if the water will support life. We are plungers,
they are planners’. However, these words do not define
reality in its entirety. It is impossible to be a competent
surgeon without using higher-order cognitive skills.
Surgeons are also viewed as being overtly aggressive.
The perception of mistreatment is a major source of stress
for undergraduate medical students, and surgeons have
been identified as being one of the groups most likely to
be associated with this kind of abuse6 . In a similar study,
British Journal of Surgery 2003; 90: 10–16
J. C. Hall, C. Ellis and J. Hamdorf
Richardson et al.7 found that the students’ perceptions
of mistreatment at Wayne State University School of
Medicine were lowest for family medicine and highest
for obstetrics/gynaecology and surgery. Non-white men
reported the worst treatment.
Selection
It is natural for surgeons to try to preserve the standing
of their profession by selecting trainees who appear to be
similar to themselves. This is a group instinct that has
both good and bad aspects. The good side relates to the
preservation of professional standards and the selection of
people who, by their innate characteristics, appear to have
a high chance of being successful. On the down side, it
is possible that good candidates are being excluded and
that intuition is not necessarily reliable. But this external
selection process is transparent and open to challenge,
whereas the key preceding process of ‘self-selection’ is less
visible. It is natural for medical students considering a
career in surgery, as well as residents wishing to choose
a surgical specialty, to be markedly influenced by role
models8,9 . Some will be attracted by the ‘men of action’
image presented in the previous section and some will be
repelled by it; but there is one entire group of medical
graduates that does not meet this ‘men of action’ image
and, by definition, never will.
Despite the fact that in most countries women make
up approximately half of medical graduates, the number
proceeding on to surgical training is relatively small. The
American College of Surgeons recently conducted a review
of trainees enrolled in surgical programmes10 . Analysis of
the graduating cohort showed that most were Caucasian
men, usually aged between 33 and 35 years. When
programmes other than in obstetrics and gynaecology
were considered, women made up 16 per cent of those
entering and 14 per cent of graduates. Furthermore, a
study by Aufses and colleagues11 found that there was a
higher attrition rate for women, even when they were in a
programme that specifically encouraged women. There are
many reasons why women self-select to ‘opt-out’ of surgical
training programmes besides issues related to lifestyle;
women are more likely to leave to join a spouse in another
geographical location12 and there are perceptions of ‘male
bias’ and ‘negative attitudes’13 – 15 .
One of the characteristics required to manage sick
patients is the ability to live with ambiguity. Merrill
et al.16 developed psychometric measures specific to the
ambiguities encountered in acute-care situations and
determined their value in predicting medical students’
attitudes towards patients and their choice of residency.
Copyright  2002 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
ž Surgeons and cognitive processes
11
Intolerance of ambiguity was associated with an excessive
reliance on high technology, a negative orientation toward
psychological problems, and Machiavellianism, which can
be expressed as ‘the means justifies the end’ or ‘whatever
it takes’. Yet such students were more likely to pursue a
career in surgery than in internal medicine, psychiatry or
family medicine.
Survival techniques
At issue is how surgeons can survive emotionally while
working within an extremely traumatic environment.
Indeed, ‘thrive’ rather than ‘survive’ may be appropriate
because there is strong evidence that surgeons are happy in
their work. Firth-Cozens et al.17 performed a longitudinal
questionnaire study of 314 medical students who were
followed up more than 7 years after graduation. Surgeons
were the least stressed and the most happy with their
choice of career, whereas laboratory-based doctors felt
stressed and were the least happy with their choice of
career. More objective is the very low rate of alcoholism
and suicide among surgeons18,19 .
There are a number of possible explanations for why
surgeons do not suffer from anticipated stress. Besides
the selection processes already mentioned, there is a close
relationship between the performance of a meaningful
occupation and people’s perceived well-being20 ; and having
a proactive personality, which certainly characterizes
surgeons, plays an important role in moderating stress21 .
But, is there a dark side? The previous section mentioned
that doctors who choose a career in surgery may
be intolerant of ambiguity, with excessive reliance on
technology, a negative attitude towards psychological
problems, and Machiavellianism. After going through the
processes that must be endured to become a surgeon, what
is left? The concepts of insight and denial will now be
explored from within this context.
Insight is a complex form of learning. It arose as a concept
in 1925 when Wolfgang Köhler described experiments
in which chimpanzees stacked boxes and used sticks of
different sizes to capture bananas22 . Such insights are not
trial-and-error events, but rather indicate higher-order
cognitive activity – a sudden appreciation of a new way
of looking at a problem. Insight occurs when a problem
is perceived from a new and useful perspective. Junior
doctors are confronted with a heavy burden of personal
responsibility when they start to practise any form of
acute medicine. Their insight into the realities of being a
doctor can cause confusion and cynicism, which was the
basic theme in Samuel Shem’s classic entitled ‘House of
God’23 – ‘the first thing to do in a cardiac arrest is feel
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12 Surgeons and cognitive processes ž J. C. Hall, C. Ellis and J. Hamdorf
your own pulse’. An alternative is to not think about the
problems, to be emotionally blind, to ‘dumb down’. This
view is supported by Griffith and Wilson24 , who found that
as students progress through medical school they become
less idealistic toward elderly patients, those with chronic
pain and the medical profession in general.
A major problem with a lack of insight is that it leads
to inflated self-assessments25 . Charles Bosk interviewed
neurosurgical trainees who had resigned or been fired and
found that they believed they hardly ever made mistakes26 .
Unfortunately, it is difficult to identify this characteristic
when selecting trainees27 , and often impossible to provide
them with counselling.
Having too much insight can be destructive and denial is
one way to deal with problems successfully. For example,
surgeons from burns centres found it emotionally difficult
to provide psychological support to the bereaved family
after the death of a patient28 . Particular issues in this
environment are the long duration of the patient’s illness
and the devastating nature of burn injury. Yet surgeons
do not always admit to concerns about emotional stresses,
although they are evident to spouses29 . Perhaps intolerance
of ambiguity is associated with an inability to recognize
incongruence.
In all of these things, the fundamental issue is the struggle
for self-protection while avoiding insensitivity30 . As Baudry
and Wiener31 have commented, ‘It must be recognized that
a certain degree of isolation from the patient’s emotions
may be salutary and essential if the surgeon is to perform
his primary function, which is to operate, in an optimal
state’.
Surgeons as experts
Little has been written in the scientific or clinical literature
about the modus operandi of effective surgeons. It is possible
to start by looking at some historical accounts. But the
problem is that they tend to be projections of the surgical
ego, the ‘eye of an eagle, heart of a lion’ stereotype.
In 1935, Professor Frederick Wood-Jones eulogized the
concept of ‘master surgeons’32 . Borrowing on attributes
of great surgeons from the past, master surgeons were
idealized as being: dedicated anatomists who were ‘lifelong dissectors and operators on the cadavers’; sensitive
humanitarians with a ‘feeling of intense pity for the
suffering’; individuals with an ‘inordinate capacity for
hard work’, the holders of ‘outstanding personalities’;
and judiciously dexterous: ‘Skillful though they were and
dexterous to a remarkable degree, the master surgeons
regarded operations only as a last resort’. It is important
to go beyond such stereotypes, and in the absence of hard
Copyright  2002 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
Table 1
The traits of experts
Focused on to a specific area
Can work fast under pressure
Spend time thinking about problems
Automation of problem-solving processes
Early recognition of difficulties
An intuitive grasp of situations
A rich professional memory
Ability to develop broad concepts
Monitor their own performance and worry
Highly motivated and proud
information, a convenient starting point is to consider the
traits that are held by all experts.
There is a general field of knowledge about experts
that is derived from comparisons between experts and
novices33,34 . It is useful to consider these two extremes,
although the acquisition of expertise is really a continuum
of learning that extends from the novice through
various stages of proficiency until the status of expert
is reached. This is the ultimate level that extends beyond
mere competence.
Table 1 lists the main traits that characterize experts.
They are both quantitative (e.g. speed and accuracy) as well
as qualitative (e.g. intuitive decision making). Although all
of these characteristics can be applied to surgeons, it can be
difficult to identify experts. Experience from other groups
suggests that the accolade of one’s peers is not generally
considered to be enough because of the confounding effects
of self-promotion and professional charisma. In one study,
which sought to identify expert teachers35 , the investigator
did not rely only on the opinions of the teachers’ colleagues,
but also considered student growth scores and made direct
observations.
Experience
Experience does not guarantee expertise, but it is
impossible to become an expert without considerable
experience. The often-used phrase ‘born to be good, train
to be great’ can be supported with good evidence. Helsen
et al.36 studied the progress of international, national and
provincial soccer players based on accumulated practice,
amount of practice per week, and relative importance and
demands of various practice and everyday activities. They
found a positive linear relationship between accumulated
practice and skill.
A report from the American Board of Surgery37 , based
on a review of the operative logs of 2434 general surgeons,
found that practice volumes were very heterogeneous with
major index cases being largely restricted to less than 10 per
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J. C. Hall, C. Ellis and J. Hamdorf
cent of the total surgical workforce. The implications of
this are unclear, but some operations are best performed by
surgeons who are trained and experienced in that particular
area. This particularly applies to rectal surgery38 , but it may
not be so for all operations. In 1998 the National Veterans
Affairs Surgical Quality Improvement Program39 reported
the risk-adjusted morbidity and mortality rates after major
surgery in 123 Veterans Affairs Medical Centers. A review
of the database, which included 417 944 major surgical
procedures, indicated that there are many situations in
which ‘system competence’ is of foremost importance.
However, it is hard to design systems and tactics to
reduce the probability of making errors associated with
poor cognitive function40 .
Decision making
It is generally held that the ability to perform a procedure
needs to be accompanied by a thoughtful approach to
its application. Spencer41 thought that 75 per cent of
the important events in an operation related to making
decisions, and only 25 per cent to manual skill. As Sir
Frederick Treves wrote in 1891, ‘The actual manipulative
part of surgery requires no very great skill and many an
artisan shows infinitely more adeptness in his daily work . . .
It is in the mental processes involved in an operation
that not a few fail. There is some lack in . . . the capacity
for forming a ready judgement, which must follow each
movement of the surgeon’s scalpel’42 .
Seemingly independent factors such as gender, personality, communication skills and age, can coalesce to
influence surgical decisions. For example, with regard to
breast disease, male surgeons are more likely to perform a
mastectomy than female surgeons43 , while surgeons who
provide better information are more likely to perform a
lumpectomy44 . In addition, the older surgeons are, the less
likely they are to take risks45 . Less clear is the effect of new
technology on clinical performance46 .
In 1996, the cost for a single 1-year survivor from
a surgical intensive care unit was estimated to be US
$282 61847 . It is generally appreciated that there is a need
to reduce futile care by the selection of appropriate patients
for intensive care48 . There is, however, a narrow margin
for error, and cultural and social values influence decision
making. Japanese healthcare is characterized by the fact
that the fee schedule does not reward high-technology
medicine, such as surgery and critical care. However, in
spite of the low reimbursement, the critical care practice
pattern is characterized by the futile treatment of terminally
ill patients49 . Of course, the other side to the argument
about futile care is the concern that elderly patients might
be denied appropriate surgery50 .
Copyright  2002 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
ž Surgeons and cognitive processes
13
Error avoidance
It has been suggested that there is a need to adopt
ubiquitous error reduction strategies in areas of high
risk51 . Incident monitoring borrows its methodology from
the well proven airline industry strategy in which ‘near
miss events’ are treated as seriously as actual events. This
is a very useful strategy because a near miss is often a
pointer to the need to correct an inherent underlying
problem. For example, Thomas et al.52 studied aviation
accidents in Alaska between 1990 and 1998. Although
Alaskan geography and climate do increase aviation risks,
many accidents were attributed to pilot error. In another
study, National Transportation Safety Board data were
analysed for all cases of death, serious injury or major
damage involving commuter aeroplanes53 . Three-quarters
of cases involved inadequate pilot performance, notably
poor handling of emergencies. The areas of human
performance psychology and the analysis of complex
systems are becoming of greater relevance in the avoidance
of error in surgery.
Risk management should be integrated into all levels of
surgical training. The Harvard Medical Practice Study54
reviewed the records of 30 121 randomly chosen patients
in acute-care, non-psychiatric hospitals in New York
State. They avoided trivial and transitory problems; their
criterion was ‘an injury that was caused by medical
management (and not the disease process) that either
prolonged the hospitalization, produced a disability at the
time of discharge, or both’. Adverse events occurred during
4 per cent of hospital admissions in New York State in 1984
and 28 per cent of these were due to negligence, defined
as care that fell below the standard expected of physicians
in their community. Of all adverse events, 48 per cent
related to surgical care and 17 per cent of these were due
to negligence.
The Utah Colorado Medical Practice Study provides
additional data on perioperative events55 . It found that the
incidence of adverse events after surgery was 3 per cent, of
which 54 per cent were preventable. Eight operations were
classified as ‘high risk’ based on their preventable adverse
event rate: lower extremity bypass (11 per cent), abdominal
aortic aneurysm repair (8 per cent), colon resection (6 per
cent), cardiac surgery (5 per cent), transurethral resection
of the prostate or of a bladder tumour (4 per cent),
cholecystectomy (3 per cent), hysterectomy (3 per cent) and
appendicectomy (2 per cent). Among all surgical adverse
events, 6 per cent resulted in death, accounting for 12
per cent of all hospital deaths in Utah and Colorado.
Technique-related complications, wound infections and
postoperative bleeding produced nearly half of all surgical
adverse events.
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14 Surgeons and cognitive processes ž J. C. Hall, C. Ellis and J. Hamdorf
Leadership
Schwartz and Pogge56 have identified that it is necessary
for surgeons to develop ‘the technical skills necessary
for major leadership/management roles that will both
change and empower the local healthcare service delivery
environment’. Such skills include strategic and tactical
planning, persuasive communication, negotiation, financial
decision making, team building, conflict resolution and
interviewing. Probably, few of us will reach such heights,
but one of the main characteristics of surgeons is their
ability to lead others. Many surgical achievements, such as
those of the early transplantation surgeons57 , have melded
great creativity with determination.
Cognitivism in surgical education
Cognitivism can be represented as an educational
philosophy58 . The cognitivist approach seeks to provide
a framework for attitudes, beliefs and values. It is based on
the assumption that learners actively construct their world
according to their experiences. Here, the focus is away
from reproductive learning and memory towards thinking,
reasoning and understanding (Table 2). It embraces the
types of topic that have been discussed in the previous
sections of this article.
The cognitivist approach contrasts with the more
prevalent behaviouralist approach, which emphasizes
observed behaviour rather than internal processes. The
behaviouralist approach to operative surgery is typified
by attitudes such as ‘see one, do one, teach one’, with
an emphasis on the number of completed procedures. It
represents the way things used to be done, rather than a
useful model for the future. Reductions in the hours that
surgical trainees can work signals an end to learning by
‘service saturation’. It is becoming necessary to exploit the
educational value of every experience in an effort to reduce
the length of the learning curve for new procedures59 – 62 .
Promoting higher-order cognitive skills
recognize important relationships, evaluate conclusions
drawn from data, and appraise evidence. The successful
performance of surgery draws upon these higher-order
cognitive skills. Mechanisms that have been used to
promote deeper learning include problem-solving within
structured-knowledge formats63 , the development of
critical evaluation techniques64,65 , and involvement in
teaching66 . Perhaps surprisingly, there is no firm evidence
in support of the conventional wisdom that such traits
are developed by involvement in a compulsory period
of research.
How can judgement be taught? There is little
information available on the relationship between learning
styles and surgical decision making. However, it is
appreciated that there are many different styles of learning:
concrete experience, abstract conceptualization, active
experimentation and reflective observation67 . Lynch et al.68
have stressed that clinical performance ‘requires additional
cognitive skills and abilities, and behaviors that are not
adequately reflected in objective measures of academic
performance’. Formal mechanisms for enhancing problemsolving skills include involvement in the development
of clinical algorithms68 and the evaluation of decision
anlayses69,70 .
Regrettably, higher-order cognitive functioning can
be influenced adversely by external factors. A study of
surgical house officers found that cognitive functioning and
emotional state were adversely influenced by a weekend on
call71 . Concern over resident work hours prompted a study
of the stress associated with surgical training programmes.
A sample of 257 surgical trainees reported loss of sleep
and exhaustion associated with nights on call72 . Despite
this, they had no evidence of more emotional stress than
trainees in other specialties. Although the surgeons were
more likely to have used alcohol during the previous
month, they were less likely than their contemporaries in
other disciplines to have used marijuana, cocaine or other
drugs. It seems, at least superficially, that those training in
surgery cope well with the extreme stresses of the training
programme.
Higher-order cognitive skills involve the ability to
identify central issues and assumptions in an argument,
Conclusion
Table 2
Characteristic of a cognitive approach to education
A focus on the solving of real problems
Reasoning and understanding are valued more than memory
An emphasis on the mastering of important concepts
The promotion of rigorous analysis
The justification of actions
A knowledge base that is well structured and relevant
Copyright  2002 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
Changes in technology and societal values influence the
way in which surgery is practised and the types of people
who are attracted towards surgery as a career. These
forces will gradually change the face of surgery and alter
perceptions about what it means to be a surgeon. This
evolutionary process will be aided by a greater appreciation
of the underlying cognitive processes.
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British Journal of Surgery 2003; 90: 10–16
J. C. Hall, C. Ellis and J. Hamdorf
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Copyright  2002 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
www.bjs.co.uk
British Journal of Surgery 2003; 90: 10–16