Research Project Final Report
Research Project Final Report
Principal investigator / Susan Moug / Institution / Royal Alexandra Hospital, PaisleyProject Title / The Edinburgh Delphi: WhEn to avoid or defunction a rectal anastomosis: what behaviours and situational factors underlie the decision-making pathway?
Start date / 4th April 2016 / Finish date / 4th April 2016
Lay Summary
(max 500 words)
Please use the following format:
a) Problem addressed, background and strategic significance
b) Method(s) used
c) Results and implications for treatment/understanding / a) Despite surgeons achieving the same certification to be qualified in the U.K., variation in the practice of bowel surgery continues to exist. This is seen in the case of patients with bowel cancer where at operation the surgeon has three choices to make that influence the outcome for each patient: to join the two ends of bowel (anastomosis); to join but perform a temporary stoma that can be reversed at a later date (ileostomy) or not to join and form a permanent stoma (end-colostomy). Clearly each patient is an individual and the choice made is based on patient factors including pre-surgery health. For example, if the patient has a lot of heart conditions, the surgeons may decide to perform a permanent colostomy as the risk of the anastomosis leaking (i.e. breaking down) is high and may result in the patient becoming extremely unwell, leading to their death. However, even in apparently similar cases, surgeons will vary in their anastomotic choice raising the possibility that such a choice is also influenced by the surgeon’s personality. As a result, this study aimed to define the personality traits of colorectal surgeons and analyse their influence on the anastomotic decision in patients with bowel cancer.
b) Using a modified Delphi approach (a process whereby ‘experts’ in the room are guided through questions and asked to vote and discuss to try to achieve a consensus to the question), 50 attendees of ACPGBI 2016 conference underwent questionnaire personality testing: alexithymia score (inability to understand emotions); type of thinking process used (intuitive, fast, reflex versus rational, slow) and personality traits (extraversion; agreeableness; openness; emotional stability; conscientiousness). Questions were then answered regarding anastomotic decisions in various clinical scenarios with visible real-time voting displayed on screens in the room and facilitators leading a room discussion. Results were analysed to reveal any influence of the surgeon’s personality on anastomotic decision.
c) Variation in practice was confirmed from the range of answers to the clinical scenarios. Colorectal surgeons reported being low in alexithymia (so capable of understanding their own and others’ emotions), mainly intuitive thinkers and higher than the normal population in the personality traits of emotional stability (ability to remain calm) and conscientiousness (organised, methodical). Personality traits were found to influencethe next anastomotic decision if: recent criticism at a Morbidity and Mortality meeting (a departmental meeting where poor outcomes are openly discussed with colleagues) (if low in conscientiousness); working with an untrusted anaesthetist (if high in alexithymia or low in openness) and if they had had no anastomotic leaks for >1 year (if high in openness).
d) Colorectal surgeons have speciality relevant personalities that influence the decision to join with or without a stoma in patients with bowel cancer. This could potentially explain the variation in surgical practice across the U.K.and requires further work.
Background(purpose for project) / Much of the previous work on how the decision to form a join (anastomosis) or form a stoma in bowel surgery for cancer is made has focused on patient factors (e.g. cardiac disease, frailty). However, even with similar cases with similar patients, surgeons will make different anastomotic decisions. One relatively unexplored area that may influence this anastomotic decision is the personality of the surgeon.
Introduction / Heuristics (or decision-making processes) is an evolving area in colorectal surgery. To date, work has shown that increasing age and propensity for taking risks in everyday life (gambling etc.) leads the surgeon to be less likely to form a stoma in patients with rectal cancer. At the time of writing, a colorectal surgeon’s personality has not been defined nor scrutinised for any influence on anastomotic decision-making.
Methods / Using a modified Delphi approach, 50 attendees of ACPGBI 2016 conference underwent personality testing: alexithymia score (inability to understand emotions); type of thinking process used (intuitive versus rational) and personality traits (extraversion; agreeableness; openness; emotional stability; conscientiousness). Questions were answered regarding anastomotic decisions in various clinical scenarios and results analysed to reveal any influence of the surgeon’s personality on anastomotic decision.
Results / Participants were: male (86%); consultants (84%); England based (68%). Alexithymia was low (4%) with 81% displaying intuitive thinking (reflex, fast). Participants scored higher in emotional stability (ability to remain calm) and conscientiousness (organised, methodical) compared to the normal population. Personality traits influenced next anastomotic decision if: recent Morbidity and Mortality meeting criticism (if low in conscientiousness); working with an untrusted anaesthetist (if high in alexithymia or low in openness) and no anastomotic leaks for >1 year (if high in openness).
Discussion and conclusion / Colorectal surgeons have speciality relevant personalities that influence the anastomotic decision. This could potentially explain the variation in surgical practice across the U.K. raising the potential for performing interventions that optimise surgical practice and patient outcomes.
Recommendations for future work / First, repeating Edinburgh Delphi in a larger colorectal population to validate these initial findings. Second, use another colorectal population to assess if cultural differences exist. Third, relate all personality findings to patient outcomes using established database to establish best practice (e.g. National Bowel Cancer Audit). This could lead to the development of interventions to identify, educate and modify personality traits of colorectal surgeons to optimise anastomotic decisions for patients with rectal cancer.
Publications and presentations relating to this work. (Please include anticipated outputs and submitted publications and email to confirm these as soon as possible) / Invited oral presentation at ACPGBI 2017.
Written paper in final draft stages (Annals of Surgery or Colorectal Disease).
Dissemination of results through ACPGBI social media.
Potential of further presentation/ abstract at overseas conference (perhaps to advertise potential future collaboration).
References / 1. Decision-making in rectal surgery. MacDermid E, Young CJ, Young J, Solomon M. Colorectal Disease 2013; 16: 203 – 208.
2. Risk-Taking Differences Across the Adult Life Span: A Question of Age and Domain. Rolison JL, Hanoch Y, Wood S, Liu P-J. J Gerontol B Psychol Sci Soc Sci 2014;69 (6): 870-880.
3. Heuristics and bias in rectal surgery. MacDermid E, Young CJ, Moug SJ, Anderson RG, Shepherd HL. International Journal of Colorectal Disease. 2017. Published first online 25th April 2017.