BACKGROUND: 'Slowing down when you should' has been described as marking the transition from 'automatic' to 'effortful' functioning in professional practice. The ability to 'slow down' is hypothesized as an important factor in expert judgment. This study explored the nature of the 'slowing down' phenomenon intraoperatively and its link to surgical judgment.

METHODS: Twenty-eight surgeons across different surgical specialties were interviewed from four hospitals affiliated with a large urban university. In grounded theory tradition, data were collected and analyzed in an iterative design, using a constant comparative approach. Emergent themes were identified and a conceptual framework was developed.

RESULTS: Surgeons recognized the 'slowing down' phenomenon acknowledging its link to judgment and described two main initiators. Proactively planned 'slowing down' moments were anticipated preoperatively from operation-specific (tying superior thyroid vessels) or patient-specific (imaging abnormality) factors. Surgeons also described situationally responsive 'slowing down' moments to unexpected events (encountering an adherent tumor). Surgeons described several influencing factors on the slowing down phenomenon (fatigue, confidence).

CONCLUSIONS: This framework for 'slowing down' assists in making tangible the previously elusive construct of surgical judgment, providing a vocabulary for considering the events surrounding these critical moments in surgery, essential for teaching, self-reflection, and patient safety.