Professional Documents
Culture Documents
9 August 2009
Evidence-based Medicine for Surgeons
Risk tolerance and bile duct injury: Surgeon characteristics, risk-taking preference, and
common bile duct injuries
Authors: Massarweh NN, Devlin A, Symons RG, et al
Journal: J American College of Surgeons 2009; 209:17–24
Centre: University of Washington, Seattle, USA
The most significant risk of laparoscopic cholecystectomy is common bile duct injury (CBDI). In
an attempt to prevent this serious problem, studies have been undertaken to identify factors that
can be controlled. Some aspects, such as the process and structure of care, are studied with
BACKGROUND relative ease; other factors are more difficult to quantify. A topic not traditionally studied is the
influence of an individual’s personality on everyday clinical decision making and practice,
specifically, the role of risk-taking behavior and risk preference in CBDI.
RESEARCH QUESTION
IN SUMMARY
Population Risk-taking behaviour and common bile duct injury
A random survey of Fellows of the Reported CBDI No CBDI 'p'
American College of Surgeons.
Number 534 (37.8%) 878
Indicator variable
JPI score (mean) 12.2 11.9 0.23
Self-reported, common bile duct
injury after laparoscopic Age of surgeon (mean) 52.8 yrs 51.3 yrs 0.004
cholecystectomy.
Duration in practice (yrs) 20.8 18.9 0.001
Outcome variable Lap training in residency 55.4% 63.3% 0.01
Primary: Risk preference of Lap training in a course 38.2% 29.8% 0.01
surgeons as assessed by the
Jackson Personality Index (JPI).
Comparison Authors' claim(s): “...We did not find any statistically significant difference
Surgeons not reporting CBDI. in the distribution of risk-taking preference scores between injuring and
noninjuring surgeons.”
EBM-O-METER
Evidence level Overall rating Bias levels
Double blind RCT Sampling
Randomized controlled trial (RCT) Comparison
Trash Swiss Safe News-
Prospective cohort study - not randomized cheese worthy Measurement
Life's too Holds water
short for this Full of holes “Just do it”
Case controlled study
Interestingl | Novel l | Feasible l
Case series - retrospective Ethical l | Resource saving l
© Dr Arjun Rajagopalan
SAMPLING
Sample type Inclusion criteria Exclusion criteria Final score card
Simple random A random sample Not stated Survey details
of 4100 members of
Stratified random Target ?
the American
Cluster College of Surgeons Accessible 4100
Consecutive Intended 1756
Convenience Drop outs 344
Judgmental Study 1412
Sampling bias: The study was restricted to members of the American College of Surgeons. The response rate to
the survey was 35%.
COMPARISON
Randomized Case-control Non-random Historical None
Controls - details
Allocation details Responses from self-identified CBDI injuring surgeon were compared with noninjuring
surgeons.
Comparability -
Disparity -
MEASUREMENT
Measurement error
Device used Device error Observer error
Gold std.
Scoring
Blinding
Repetition
Protocols
Y ? N
The Jackson Personality Index (JPI) is a well-established assessment tool, with risk-taking as 1 of 15 personality
subscales. The JPI risk-taking subscale in its entirety is composed of 20 questions. The complete assessment was too
lengthy and was shortened to six questions that are shown in the table below.
Measurement bias: The JPI was self-administered. The CBDI was self-reported. All of which hardly makes for an
objective assessment.
© Dr Arjun Rajagopalan