Clinical ScienceThinking like an expert: surgical decision making as a cyclical process of being aware

•The cyclical nature of surgeon's decision making during challenging and unexpected situations requires a higher degree of awareness.•The core element of the decision-making process used by experienced surgeons to assess and respond to challenges can be described by a reconciliation cycle.•Advancing the notion of situation awareness in surgery is required to better understand how expert surgeons create and implement strategies to cope with unexpected events.

BackgroundEducation researchers are studying the practices of high-stake professionals as they learn how to better train for flexibility under uncertainty. This study explores the “Reconciliation Cycle” as the core element of an intraoperative decision-making model of how experienced surgeons assess and respond to challenges.MethodsWe analyzed 32 semistructured interviews using constructivist grounded theory to develop a model of intraoperative decision making. Using constant comparison analysis, we built on this model with 9 follow-up interviews about the most challenging cases described in our dataset.ResultsThe Reconciliation Cycle constituted an iterative process of “gaining” and “transforming information.” The cyclical nature of surgeons' decision making suggested that transforming information requires a higher degree of awareness, not yet accounted by current conceptualizations of situation awareness.ConclusionsThis study advances the notion of situation awareness in surgery. This characterization will support further investigations on how expert and nonexpert surgeons implement strategies to cope with unexpected events.