Purpose: Previous investigations have shown that vascular surgeons and lay adults, when presented with updating rupture risk statistics for an hypothetical patient or abstract representation of an expanding Abdominal Aortic Aneurysm (AAA)/balloon, do not rely exclusively on statistical guidelines when deciding about when to choose surgical repair. Additionally, both groups are significantly influenced by a prior simulated early AAA/balloon analogue rupture so that their decision making in the following simulated case is altered. This field experiment of surgeons and geriatricians increased the clinical realism and simulation detail from the previous AAA simulation and tested two hypotheses: First, that when physicians experience a realistic simulated patient’s AAA rupture, it influences them to choose surgery earlier with a subsequent patient. Second, that when they experience a simulated perioperative death they delay surgery longer, even when statistical risk-based guidelines are presented.
Method: Participants were (N=63) surgeons and (N=69) geriatricians at two professional conferences who, with double-blind random assignment, were presented with one of three demonstrations of AAA treatment outcomes during their “practice” simulation round: 1) AAA ruptures early while following, 2) Patient dies perioperatively when sent to surgery, 3) Control: surgery, when chosen, is successful. Participants then made incentivized decisions about the timing of surgery for a subsequent simulation patient and the number of times the decision to continue watchful waiting was chosen was recorded. Using Cox proportional hazards regression, several predictors of following time to surgery were tested.
Result: After controlling for demographics, baseline anxiety, intolerance for uncertainty, attitudes towards risk taking, and the impact of simulation characteristics, observing an AAA rupture powerfully influenced the timing of the decision to go to surgery in the subsequent simulated patient. (HR=1.87, p=.01). No significant difference was observed between the groups who assigned to the simulated perioperative mortality and the group with a successful surgery. No significant difference between surgeons and geriatricians was found.
Conclusion: When presented with a realistic AAA patient simulation with updated statistical risks associated with each decision, both surgeons and geriatricians are influenced by the experience of an AAA rupture in the previous simulated patient and chose to go to surgery earlier than advised by published guidelines.
Candidate for the Lee B. Lusted Student Prize Competition