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The quality of an operation depends on operative technique. There is very little evidence, however, regarding how surgeons arrive at their intraoperative decisions. The objective of this study was to determine the extent to which practicing surgeons participating in a coaching program justify their technical decisions based on their experience or based on evidence.This qualitative study evaluated 10 pairs of surgeons participating in a video review coaching program in October 2015. Using thematic analysis, the conversations were coded in an iterative process with comparative analysis to identify emerging themes.Three major themes emerged during analysis: (1) Individuals often reported modifications in surgical technique after a negative postoperative complication; (2) participants were noted to defend the use of certain techniques or surgical decisions based on the perceived expert opinion of others; and (3) surgeons rarely referred to evidence in surgical literature as a motivation for changing surgical technique.In this qualitative analysis of coaching conversations we found that practicing surgeons often justify their surgical decisions with anecdotal evidence and “lessons learned,” rather than deferring to surgical literature. This either represents a lack of evidence or poor uptake of existing data.