Reactions to uncertainty and attitudes towards risk intuitively have implications on clinical decision-making. However, there is a limit in our understanding of the degree to which this issue influences surgical care [10]. Instruments have been developed in an attempt to assess risk-taking in general among physicians. Nightingale [11] developed a two-question test that has been frequently used to assess the degree to which physicians view themselves as risk seeking or risk averse (Table 4.1). These questions assess respondents’ willingness to gamble for their patients in both the face of gain and in the face of loss. Those who refuse to gamble for their patients in the face of loss are considered risk averse. In three studies that Nightingale conducted [11–13], a significant correlation was found between resource utilization and risk preference in the face of loss. The more often physicians chose the risk averse gamble, the more likely they were to utilize additional resources to rule out uncertain outcomes. Most physicians in the setting of certain loss would rather minimize loss and fail in half of these attempts, than accept a certain loss. This fear of risk taking has been found to be less consistent in other studies [14], and varies based on mode of testing and across different cultures [15].

There is little data looking specifically at the impact of surgeon age and clinical decisions. Anecdotes have suggested many surgeons lack insight into the gradual degradation of their own skills. Age causes deterioration in physical and cognitive performance. Greenfield and Proctor identified cognitive factors that declined with age in surgeons including the ability to focus attention, the ability to process and correlate information and native intelligence [16]. Trunkey and Botney developed a series of tests, the “MicroCog”, that were designed to detect impaired competence occurring late in a physician’s career [17]. The tests measure reactivity, attention, numeric recall, verbal memory, visiospatial facility, reasoning and mental calculation. The authors found that in all physicians (including non-surgeons) that though they perform better than non-physicians, by age 75 they lose 25 % of their starting score. In a meta-analysis looking at all types of physicians, Choudhry and colleagues found that half of the 59 articles included for study reported declining measures of quality of care with increasing physician years in practice [18]. Other studies have shown that older physicians were less likely to adopt newly proven therapies, and may be less receptive to new standards of care [19–21]. In a study of 93 surgeons and anesthesiologists in Japan by Nakata and colleagues, the relationship between risk attitudes and demographic characteristics were explored in case vignettes assessing whether respondents were risk averse, risk neutral and risk seeking [22]. The only positive finding was with regards to age – the older the physician, the more risk averse they were. The study concluded that older physicians might shy away from risk, while younger physicians may be more willing to gamble.

However, it is unknown what influence emergence of the evidence-based care movement and maintenance of certification programs will have on any interaction of surgeon age and decision-making.

There has been a dramatic change in the number of women entering the physician workforce over the past three decades [23]. Women make up close to half of all US residents and fellows – increasing from 21.5 % in 1980 to 45.4 % in 2010. Change however is coming more slowly in many of the surgical specialties, where women are still a distinctly small minority. As fewer than 5 % of cardiothoracic surgeons are women [24], the impact of surgeon gender and decision-making have not been assessed. There have been small studies comparing communication styles between male and female physicians [9]. Female doctors were found to actively facilitate patient participation on medical decisions by enacting methods such as partnership building, positive talk, question asking, and information giving [9, 25, 26]. Female doctors were less dominant verbally during clinic visits as compared to males and engaged in active discussions with patients.

Surgeon specialty has been shown to be associated with better post-operative outcomes among high-risk operations [27]. Goodney and colleagues [28] demonstrated that board-certified thoracic surgeons have lower rates of operative mortality with lung resections compared to general surgeons, although they noted that other factors such as hospital volume also influenced a patient’s operative risk of mortality. In a lung cancer resection study conducted by our group in the SEER-Medicare population [29], we found that board-certified general thoracic surgeons had greater long-term survival rates than those treated by general surgeons. General thoracic surgeons performed preoperative and intraoperative staging more often than general surgeons or cardiothoracic surgeons (those who performed both cardiac and thoracic procedures as part of their practice). In esophageal cancer surgery, Dimick and colleagues [30] found that specialty board certification in thoracic surgery was independently associated with lower operative mortality rates. Common themes in these studies were influence of provider volume on the overall effect, as well as more consistent process-of-care measures by specialty surgeons. As there is a trend towards increasing specialization amongst surgeons, other factors that may have influenced decision-making include training in the modern era, with inclusion of evidence-based protocols, and multi-disciplinary participation in tumor boards amongst specialists. It is unknown if subspecialty-trained surgeons are more risk seeking in their treatment options in light of additional training experience.

The Patient Protection and Affordable Care Act (ACA) signed into law in March 2010 seeks to improve health care delivery in several ways, from access to quality to cost. ACA’s goal was to create a movement of payment reforms, in which private insurance companies would follow the lead of successful government payment reforms, such as bundled payments, and ultimately create system-wide changes for reimbursement [31]. Changing the reimbursement structure for providers will inevitably create new issues for surgeons who are making decisions for their patients. Most of the payment reforms began in 2011 and 2012, and will continue through 2016. Two programs designed to restructure the way health care is delivered have been proposed under ACA, namely Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs). These programs are designed to improve care coordination by encouraging use of electronic medical records, changing providers’ financial incentives by including quality measures in reimbursement, and ultimately moving away from a fee-for-service to one where quality of care is valued [32].

The ACO movement has led to increased consolidation and integration in the medical marketplace. Hospitals are buying practices, which means that physicians are ceding autonomy to belong to the organizations to keep their market share intact and to have access to electronic record systems and other infrastructure that are expensive to capitalize. Awareness emerges for surgeons that their medical decisions can potentially negatively influence their income. This is not necessarily unethical, as cost containment has been recognized as an important circumstance in good decision-making [33]. There will be penalties, which could affect physician reimbursement. Adoption of rigid guidelines for the treatment of patients may limit individual surgeon decision-making, as well as expansion of treatment pathways and care plans. All of these are attempts at decreasing variation in care, decreasing length of stay, and reducing use of resources.

Surgeons in the Veterans Administration hospital system have participated for more than a decade in a systematic data-gathering and feedback system of outcomes for major surgery [34]. The National Surgical Quality Improvement Project (NSQIP) works to decrease variation in clinical outcomes by demonstrating to surgeons when their center is an “outlier” in performance. This system allows hospitals to target QI activities that may influence components of care, and subsequently decision-making.

Professional organizations can play a role in decision-making by effectively regulating surgeon-directed clinical practice. One example is the guidelines for laparoscopic resection of curable colon and rectal cancer [35] written by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and endorsed by the American Society of Colon and Rectal Surgeons (ASCRS). These guidelines give recommendations on tumor localization, diagnostic evaluation for metastases, preparation for operation, surgical technique, as well as minimum number of cases to gain proficiency. The society also noted that while robotic surgery appears feasible, that in the absence of long-term oncologic outcome studies, no clear recommendations were made. Guidelines such as these influence members, and are in stark contrast to the situation of non evidence-based decision-making that existed for LVRS prior to NETT.

The reporting of surgeon-specific outcome data is another example of the influence of the political environment. Outcome data were rarely reported prior to the mid-1980s [36]. The first release of hospital open heart surgery risk-adjusted mortality rates in December 1990 [37] and the first formal public report in December 1992 [38] marked the start of a new era. These performance reports, or physician report cards, have increased in frequency in recent years [39]. Advocates of this form of reporting believe they provide information about quality of care that consumers, employers, and health plans can use to improve their decision-making and to stimulate quality improvement among providers [40]. They may also appropriately promote regionalization of medical centers and consolidation of resources. However, physicians are concerned that risk adjustment strategies in these reports are not adequate. Without this confidence, publication of procedural mortality rates may result in physicians withholding procedures in high-risk patients. In a study by Narins and colleagues [39], the attitudes and experiences of cardiologists were surveyed about the influence of the New York Percutaneous Coronary Intervention (PCI) report card on their decision-making process. Eighty-nine percent agreed or strongly agreed that patients who might benefit from PCI may not receive the procedure as a result of public reporting of physician-specific mortality rates. Seventy percent agreed or strongly agreed that the presence of a scorecard influences whether they treat a critically ill patient with an expected high mortality rate. The authors concluded that unintended consequence of scorecards might be to adversely affect healthcare decisions for especially high-risk patients. Scorecards may also impair the development of new treatments because of the more restrictive clinical practice environment [40].