Dissecting the role of anatomy in guidance for intraoperative clinical reasoning

BACKGROUND: Anatomy is indispensable to surgical expertise, yet surgical residents often struggle to translate anatomical knowledge into safe and efficient operative decisions. This disconnect can contribute to errors, hesitation and missed opportunities for autonomy. Despite the centrality of anatomy in surgical practice, research has rarely examined how surgeons draw on anatomical knowledge in their clinical reasoning and how residents learn to do so under real operative pressures. This blind spot means that opportunities to deliberately cultivate reasoning skills anchored in anatomy may be overlooked. METHOD: A constructivist grounded theory approach was used to analyse observational and interview data to explore the role of anatomy in interactions between surgeons and residents to guide intraoperative clinical reasoning. Participants included general surgery consultants and residents at three Canadian academic hospitals. Field notes were documented by observing participants throughout six operative days, capturing 16 individual operations. Follow-up semi-structured interviews were completed with six surgeons and eight residents. RESULTS: Three themes representing different guidance interactions were developed: establishing trust, aligning understanding throughout operative progress and teaching future decision-making. Using these themes, a model of anatomy-based guidance interactions was created showing how anatomy functions as a shared communication tool, serves as common landmarks for operative progress and helps make clinical reasoning processes explicit. CONCLUSIONS: The power of explicitly verbalising anatomy in surgical guidance interactions lies in making tacit reasoning processes accessible. Anatomy facilitated bilateral communication that created and maintained a shared mental model for residents and surgeons throughout an operation, allowing surgeons to understand a resident's thinking and enabling residents to see how surgeons connected foundational knowledge to surgical decision-making. Through explicit use of anatomy-based guidance, these interactions simultaneously scaffolded residents' in-the-moment decision-making and developed their clinical reasoning for future operations.