Surgery Is a Team Sport

As a Vascular Surgeon, I have had the honor and privilege of serving not only as an Attending Surgeon, but as a Division Chief, Professor of Surgery, Surgical Residency Director and Chairman of Surgery. One’s perspective on incivility in the operating room (OR) depends on one’s position and responsibility. I was trained during a period of time when bombastic behavior by the senior surgeon was accepted, sometimes expected, and always legendary. Shall I admit to being a reformed sinner? Shouldn’t we all, in one way or another? My mantra to the residents, the attending staff, the OR staff (and anyone else who will listen) has always been that “surgery is a team sport.” When the team functions well, the patient does well. 

If one member of the team cannot or does not perform well, the team functions poorly and – here is the bottom line – the patient suffers. Disruptive behavior by any team member jeopardizes team performance; but more often than not, as I have said to my fellow surgeons, to quote Pogo, “We have met the enemy and he is us.”¹

The existence of disruptive behavior in the OR is well known, but its pervasiveness and its impact may be less well appreciated. A survey of physicians, nurses and nurse anesthetists at a large academic medical center² found that disruptive behavior by attending surgeons was witnessed on a daily basis by 15% of respondents and on a weekly basis by 22%. Lest surgeons take all the blame, disruptive behavior by anesthesiologists and nurses was witnessed on a daily basis by 7%. The most common forms of such behavior were reported to be yelling/raising voice (79%), disrespectful interaction (72%), abusive language (62%), and berating in front of peers (61%). Most concerning was the finding that 46% were aware of a potential [negative] event that could have occurred and 19% were aware of a specific adverse event that did occur as a result of disruptive behavior.

Consequences of Incivility

A small series of interviews³ concluded that disruptive surgeon behavior has several negative consequences. Of great clinical importance was the finding that such behavior shifted focus from the patient to the surgeon and increased errors. It was also found that respect for surgeons diminished. All too often, in my experience, these consequences are not appreciated by the offending surgeon. Helping the surgeon understand the results of their actions is an effective management technique. No surgeon can realistically defend behavior that results in such consequences.

An interesting report recognized two distinct types of conflict in the OR⁴: 1) task-related conflict was described as being principally cognitive, with team members having different opinions and making different decisions; 2) relationship-based conflict was considered emotional in nature and may be based on or create interpersonal discord. Both can reduce team member satisfaction, and the latter has a strong negative impact on team performance. Task-related conflict may be unavoidable, so care must be taken to prevent such professional disagreements from becoming personal and morphing into relationship-based conflict. Just as a good debater is trained to avoid “ad hominim” (wherein an argument or position is rebutted by attacking the other individual rather than the position itself), team members must be taught to avoid personal attacks. When the surgeon asks for “vicryl suture,” the nurse may hand up a 3-0 suture on an SH-1 needle when the surgeon wants a 2-0 suture on a CT-1 needle – a difference of opinion. The surgeon should simply respond by specifying exactly what he/she wants (as should have been done initially!). Even if a delay is encountered while the nursing staff procures the desired suture, the surgeon should never respond by insulting the nurse’s intelligence, ability or devotion to patient care. Such a personal attack is unwarranted, cannot possibly benefit the patient, and may very well impair team function.

The culture of medicine has tolerated disrespectful behavior for far too long. Leape and co- authors observed that “Central to this culture is a physician ethos that favors individual privilege and autonomy.”⁵ They postulated that this sense of privilege can lead physicians to exhibit disruptive behavior when interacting with nurses and other staff, resulting in poor communication and failure to receive appropriate feedback.

The sense of autonomy leads physicians to ignore institutional policies and procedures designed to increase patient safety. This concept is often referred to as “Crew Resource Management” because the OR, in this respect, is not dissimilar to the flight deck of a complex aircraft. Copilots and navigators may notice issues that the pilot does not, and safety demands that they communicate such findings to the pilot, even to the extent of pointing out pilot error. The same need exists in the OR, but a nurse who has suffered insults and abusive behavior is less likely to communicate an error or a potential error to a surgeon. Patient safety suffers. Prior to takeoff, the flight deck crew must run through their pre-flight checklist – even when the flight is already delayed, the passengers impatient, and the crew pressured to maintain the schedule. Although tedious, time-consuming and rarely productive, all crew members will mandate that it be done – their lives may depend on it. When the surgeon is running late and pressured to complete his/her schedule on time, the surgeon may ignore such critical checklist items as patient identification, proper site identification, surgical checklists, and rechecking medication and blood product identification. If these procedures are ignored or performed perfunctorily, patient safety suffers.

Patient Safety

The logical assumption that disruptive behavior results in patient harm has been repeatedly reinforced by interviews, surveys, focus groups and other methods of subjective evaluation. A recent small but well-designed randomized study⁶ took a more objective approach. Two teams were observed providing care in a mannequin simulation of a neonate in distress. One group was exposed to scripted rude comments by a neutral observer; the control group heard neutral comments. Despite the fact that the rude comments were not directed at any member of the team, exposure to even such a minor form of disrespectful behavior had a significant negative effect on team performance. Both diagnostic ability and technical, procedural performance were impaired. Performance decreased in all ten measures of diagnostic acumen and was significant (p<.01) in half. Procedural performance was also negatively affected in all ten measures and was significant (P<.01) in more than half. This clear relationship between disruptive behavior and patient safety demands that the problem be addressed – but it also may provide the key to changing the culture of healthcare.

Disruptive behavior can, and does, occur in almost every healthcare setting. If the root cause of such behavior is, as many believe, the high-stress environment and the disparate levels of authority and power among team members, then it is this most likely to occur in the OR where patients’ lives hang in the balance. If disruptive behavior negatively impacts patient safety, nowhere will this have greater and more immediate impact than in the OR.

Changing the Culture

To solve the problem, we need to change organizational culture; the question is how that can best be accomplished. There is general agreement that leadership is responsible for effecting change. Policies and procedures with regard to disrespectful behavior must be established and followed. Team members must be encouraged to report such behavior and be protected from the consequences of reporting. All members of the team, without exception or variation, must be held accountable. The devil, however, is in the details – and controversies exist.

Every institution is different, every department distinctive, and every individual unique. What works best in one setting may not work well in another. I cannot give you a magic formula that will resolve every problem and lead your institution to the promised land of being a high reliability organization. As a surgeon who has probably caused the problem, as a physician leader who has struggled to solve the problem, and as a consultant who has worked with others to address the problem, I can only share with you my experiences, my thoughts and my prejudices as to what works and what does not. If I were texting, I would add: “YMMV.”

The process begins by setting appropriate policies and procedures. Simply referring to “disruptive or disrespectful behavior” or “any behavior that undermine a culture of safety” is probably insufficient. With all due respect to Justice Potter Stewart, “I know it when I see it” leaves the definition up for discussion. What a nurse may “see” as rude behavior may differ markedly from what the (offending) surgeon may perceive. Specific examples are needed to elucidate what is and is not acceptable.

The critical and perhaps most controversial phase is what should occur in real time in the OR. The key is always doing what is best for the patient. If the surgeon demands that organizational safety policies (e.g., checklists, time-outs, counts, etc.) be compromised for expedience or as a display of power or autonomy, the surgical team should simply respond that the procedure is required, it is for the patient’s safety, and it will be followed. A surgeon can argue with policy and rail against controlling forces, but will not want to be perceived as sacrificing patient safety.

Disrespectful behavior targeting an individual member of the team is more difficult to respond to. Some have suggested that “failing to speak up when disrespect occurs is a serious problem that can have negative consequences for a patient.”⁷ Although there may be a strong emotional need to immediately respond and although a rejoinder may be justified and personally momentarily satisfying, it is rarely in the best interest of patient safety. As has been suggested by others,⁸ confrontation often escalates the situation rather than resolving it. The focus becomes centered on the personnel and their interaction rather than remaining centered on the patient, as it should be. The OR is not the place – and intraoperatively is not the time – to “discuss” the matter.

In the OR, disrespectful behavior, when it occurs, is almost always displayed by the senior-most surgeon in the room and is usually directed at the nursing staff – although residents and medical students are unfortunately not immune to such attacks. Due to the hierarchy which, right or wrong, exists in healthcare, it is difficult for the individual nurse to address and resolve the matter with the surgeon due to this asymmetrical relationship. If the surgeon and the nurse have a close professional rapport and share a mutual respect, such an approach might be effective; but disrespectful behavior rarely occurs under those circumstances.

An effective protocol must be established to address disruptive behavior. The protocol may vary from one institution to another, but I would suggest there are several key elements.

1. The (OR) nurse must feel free to, and be encouraged to, report such behavior to the nursing supervisor or Chief Nursing Officer without fear of retribution.
2. The nursing supervisor should not ignore or trivialize the event to avoid dealing with the matter, but should gather information – from multiple sources if possible – to fully understand what occurred.
3. The incident and the relevant facts should be communicated by the nursing supervisor or CNO to the surgical service. In my experience, the key individual is the Chairperson of the Department of Surgery whose responsibility it is to communicate with the involved surgeon. 

How that communication is framed is the key to success. Simply telling the surgeon, “You cannot do that” (he/she did, and can do so again) or “You should not treat others disrespectfully” (he/she often does not care) will rarely solve the problem. A more successful tactic might be to approach the issue as a matter of patient safety. If the surgeon has acted in a disruptive manner, ask how such behavior could possibly be in the patient’s best interest. Ask if the roles were reversed, whether the surgeon thinks such actions would help or hinder the team effort necessary for success. Advise the surgeon that the department, the Medical Staff and the organization are dedicated to patient safety. Explain that patients, not surgeons, are the highest priority and that all members of the (surgical) staff are expected to support that concept. It is implied, but rarely necessarily voiced, that surgeons who place their own feelings, their own emotions and/or their own sense of privilege above the welfare of the patient are simply in the wrong profession.

Doctors and nurses as well as laboratory, pharmacy, radiology and all healthcare staff are dedicated to their patients and their profession. They get up every day to do the best they can to care for those who place their trust in them. No one wants to be uncivil, but in this high-stress environment filled with “type A” and “alpha” personalities, avoiding undesirable behavior can be difficult. My response has always been that being a great surgeon or a great OR nurse is also difficult, so we all have the ability to show mutual respect and work as a team to achieve the best possible patient outcome. Surgery is a team sport.

 References

¹ Kelly, Walt. Poster for the First Earth Day April 22, 1970, and Pogo: We Have Met the Enemy and He Is Us. Simon and Schuster, 1972.

² Rosenstein AH and O’Daniel M. Impact and Implications of Disruptive Behavior in the Perioperative Area. J Am Coll Surg. 2006:203:96‐105.

³ Cochran A and Elder WB. Effects of disruptive surgeon behavior in the operating room. The Am J of Surg. 2015(209) 65‐70.

⁴ Rogers D, Lingard L, Boehler M, Espin S, Klingensmith M, Mellinger JD, and Schindler N. Teaching operative room conflict management to surgeons: clarifying the optimal approach. Medical Education. 2011:45:939‐945.

⁵ Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman‐Levitan S, Meyer GS, and Healy GB. A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians. Acad Med. 2012;87:845–852.

⁶ Riskin A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, Riskine KS, and Bamberger PA. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015 (136) 3:487‐495.

⁷ Clark CM and Kenski D. Promoting Civility in the OR: An Ethical Imperative. AORN J. 2017 (105):60‐66.

⁸ C Porath. An Antidote to Incivility. Harvard Business Review. April 2016.