What's behind the scenes? Exploring the unspoken dimensions of complex and challenging surgical situations.

Purpose: Physicians regularly encounter challenging and/or complex situations in their practices; in training settings, they must help learners understand such challenges. Context becomes a fundamental construct when seeking to understand what makes a situation challenging and how physicians respond to it; however, the question of how physicians perceive context remains largely unexplored. If the goal is to teach trainees to deal with challenging situations, the medical education community requires an understanding of what "challenging" means for those in charge of training.

Method: The authors relied on visual methods for this research. In 2013, they collected 40 snapshots (i.e., data sets) from a purposeful sample of five faculty surgeons through a combination of interviews, observations, and drawing sessions. The analytical process involved three phases: analysis of each drawing, a compare-and-contrast analysis of multiple drawings, and a team analysis conducted in collaboration with three participating surgeons.

Results: Findings demonstrate that experts perceive the challenge of surgical situations to extend beyond their procedural dimensions to include unspoken, nonprocedural dimensions-specifically, team dynamics, trust, emotions, and external pressures.

Conclusions: Findings show that analysis of surgeons' drawings is an effective means of gaining insight into surgeons' perceptions. The findings refine the common belief that procedural complexity is what makes a surgery challenging for expert surgeons. Focusing exclusively on the procedure during training may put trainees at risk of missing the "big picture." Understanding the multidimensionality of medical challenges and having a language to discuss these both verbally and visually will facilitate teaching around challenging situations.