• Alexander Langerman, Kathleen Brelsford, and Catherine Hammack-Aviran.
• Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN.
• Ann. Surg. 2022 Aug 1; 276 (2): 205-212.

ObjectiveIdentify the considerations academic surgeons use when determining which portions of a procedure are "critical" and necessitate their presence.BackgroundTeaching physicians are required to be present for the "critical portion" of surgical procedures, but the definition of what constitutes a critical portion remains elusive. Current guidelines defer to surgeons' expert judgment in identifying critical portion(s) of a procedure; little is known about what concepts surgeons apply when deciding what parts of a procedure are critical.MethodsQualitative analysis of interviews with 51 practicing surgeons from a range of specialties regarding their working definition of critical portions.ResultsSurgeons identified 4 common themes that they use in practice to define the critical portions of procedures: portions that require their first-hand observation of events, those involving challenging anatomy or structures that cannot be repaired if injured, and portions where an error would result in severe consequences for the patient. Surgeons also recognized contextual factors regarding the patient, trainee, surgeon, and team that might alter determinations for individual cases.ConclusionsAlthough critical portion definitions are largely treated as subjective, surgeons across multiple specialties identified consistent themes defining "critical portions'', suggesting that setting a minimum standard for criticality is feasible for specific procedures. Surgeons also recognized contextual factors that support the need for case-specific judgement beyond minimum standard. This framework of procedure features and contextual factors may be used as a guide for surgeons making day-to-day decisions and in future work to formally define critical portions for a given procedure.Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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