Understanding Cognitive Constraints and Decision-Making Processes in Modern General Surgery

Contemporary general surgery is practiced in environments characterized by high cognitive complexity, time pressure, and uncertainty, where surgeons must make rapid decisions with significant clinical consequences. While technical proficiency remains essential, increasing evidence highlights the central role of cognitive processes, non-technical skills, and system-level factors in shaping surgical performance and patient safety. This study aimed to synthesize current evidence and expert convergence regarding the cognitive and decision-making demands of contemporary general surgery and to organize these demands into a coherent framework relevant to surgical education and clinical practice. A narrative review was conducted integrating foundational and contemporary literature on cognitive psychology, human factors, and surgical safety, supported by a structured Delphi-based framework to consolidate and refine key domains through iterative thematic convergence. Findings identified six core domains: cognitive load and multitasking, fatigue and decision fatigue, cognitive bias and heuristics, non-technical skills, team communication and coordination, and system and environmental stressors. Cognitive load emerged as the central domain, closely interacting with fatigue and bias, while progressive convergence across Delphi rounds supported the robustness of the final framework. Alignment with Bloom’s taxonomy highlighted the educational relevance of these domains. Overall, surgical decision-making is a multidimensional process shaped by individual cognition, team dynamics, and system design, underscoring the need to address cognitive demands alongside technical training to enhance decision quality, surgical performance, and patient safety in contemporary general surgery.