The Equipoise Ruler: A National Survey on Surgeon Judgment About the Value of Surgery.

Objective: To understand professional norms regarding the value of surgery.

Background: Agreed-upon professional norms may improve surgical decision-making by contextualizing the nature of surgical treatment for patients. However, the extent to which these norms exist among surgeons practicing in the United States is not known.

Methods: We administered a survey with 30 exemplar cases asking surgeons to use their best judgment to place each case on a scale ranging from "definitely would do this surgery" to "definitely would not do this surgery." We then asked surgeons to repeat their assessments after providing responses from the first survey. We interviewed respondents to characterize their rationale.

Results: We received 580 responses, a response rate of 28.5%. For 19 of 30 cases, there was consensus (≥60% agreement) about the value of surgery (range: 63% to 99%). There was little within-case variation when the mode was for surgery and more variation when the mode was against surgery or equipoise. Exposure to peer response increased the number of cases with consensus. Women were more likely to endorse a nonoperative approach when treatment had high mortality. Specialists were less likely to operate for salvage procedures. Surgeons noted their clinical practice was to withhold judgment and let patients decide despite their assessment.

Conclusions: Professional judgment about the value of surgery exists along a continuum. While there is less variation in judgment for cases that are highly beneficial, consensus can be improved by exposure to the assessments of peers.