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To Thine Own Self Be True: A First Step Toward Learning How Anesthesiologists Deal With Adversity in the Operating Room

Birnbach, David J. MD, MPH*; Prielipp, Richard C. MD, MBA, FCCM

doi: 10.1213/ANE.0000000000003697
Editorials: Editorial
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From the *Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, Florida

Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota.

Accepted for publication July 2, 2018.

Funding: Departmental.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to David J. Birnbach, MD, MPH, UM-JMH Center for Patient Safety, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136. Address e-mail to dbirnbach@miami.edu.

Interpersonal and communication skills are not only a core competency for all residents1 but also an essential attribute for success as an anesthesiologist. But, while residents are supposed to be proficient in these skills, when and how do trainees actually learn them? All too often, these skills are not actively taught—instead trusting that they will be learned “on the job” through osmosis during residency training. The problem is not only that anesthesiology residents are exposed to operating room (OR) confrontation on an almost daily basis but also they may observe diverse (sometimes ill fated) approaches at conflict resolution in the absence of the needed background to understand what techniques will be most effective in a given situation.

Communications and leadership workshops have been advocated by other specialties,1,2 and some preliminary work on communication skills development, conflict management, and leadership training has been reported in the anesthesiology literature.3,4 That said, we believe that not enough attention has been paid to this important area—especially in light of the worst-kept secret in medicine—ORs are often the epicenter of conflict in hospitals where the historic hierarchical culture can magnify the impact of stress, time pressure, economic demands, and deteriorating patient conditions. As examples of daily conflict in the OR, one needs to look no further than the choice and volume of music being played or the temperature setting.

If effective approaches for dealing with difficult OR situations are to be developed, then a starting point should be for anesthesiologists and those in training to become anesthesiologists to better understand who they are and how they routinely handle adversarial situations. Many strategies exist: too assertive, they might escalate OR confrontation; too compromising, parties might not be able to appropriately advocate for the patient; and too accommodating, they might pay the steep price of reinforcing unacceptable OR behaviors while losing sight of patient priorities.

So how are anesthesiologists to learn various styles of conflict management and how to use them? Vasilopoulos et al5 have opened an important door to understanding OR conflict management by assessing conflict styles in fledgling anesthesiology residents. However, their findings, while interesting, are somewhat inconclusive. First, the cohort tested was first-year (PGY-1) anesthesiology residents. It is unclear how much (if any) actual OR time these interns had experienced, and thus this study may be seen more as a view of recently graduated medical students pursuing a career in anesthesiology than those with various degrees of advanced training in the specialty. Other complexities of conflict resolution are also unaddressed. For instance, previous reports have suggested differences in behavior patterns between faculty and residents, and it has been previously reported that resident styles may change as their training advances.2 Furthermore, we know that gender impacts many layers of conflict dynamics, but the authors did not explore or address potential gender differences. Thus, more data are clearly necessary for those seeking answers about improving communication styles among anesthesia providers. Indeed, it would be interesting for these authors to follow this specific cohort of residents during their training to see if their styles evolve as their training progresses.

Second, the approach used in this article might suggest a one-size-fits-all approach to communication and conflict management in the OR. It is interesting to note that Vasilopoulos et al5 found that most PGY-1 residents tend to resolve conflict using either an accommodating or a compromising style the most and a competing style the least. But attending physicians and other professionals interacting with anesthesiology residents should recognize that most individuals use an array of conflict-resolution styles depending on specific circumstances, hierarchical power, the perceived intensity of the issue, and a host of other factors. Furthermore, no one particular style is intrinsically superior or inferior to another. Indeed, each resolution mode has potential benefits and risks. For instance, a compromising style may be the most efficient pathway to reach a resolution under intense time pressure but may also represent the default option if 2 parties have significantly different power hierarchies. Avoidance is another technique that could represent the likelihood that other parties (eg, chief resident and program director) are more likely to successfully resolve a clinical issue or could simply indicate that 1 party no longer feels particularly vested in the outcome. By contrast, “competing” is a forceful style that can be used effectively but runs the risk of negatively impacting interpersonal relationships. While it usually facilitates a quick decision, participants should use a conflicting mode selectively, such as when the decision is critical to a positive outcome for the patient or organization. One should also recognize that the “loser” of this process will often feel defeated and may harbor resentment (then or later).

Third, use of dyad partners of coresidents is potentially problematic when undertaking a study of conflict. These partners may have had preexisting friendships with their classmates that could reduce the possibility of developing confrontational situations without requiring an enormous arrest of disbelief. In this era where simulation centers abound and the use of actors playing patients is commonplace, it may have been more useful to videotape conflicts produced by unknown actors, as opposed to using self-assessment and imagination among classmates.

Despite these small flaws, Vasilopoulos et al5 are to be lauded for highlighting this important subject to our specialty. Their finding that anesthesiology residents at 1 program predominantly use a compromising approach to conflict resolution is not surprising but nonetheless important. It is an approach where one tries to identify an “acceptable settlement that only partially satisfies both people’s concerns.”1 Is that the best approach for the person who is guardian to a patient who cannot advocate for him or herself? Maybe not, but hopefully this article will convince other investigators to more deeply explore this important subject matter and find ways to incorporate improved conflict management training into our residency programs.

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DISCLOSURES

Name: David J. Birnbach, MD, MPH.

Contribution: This author designed and authored the editorial.

Name: Richard C. Prielipp, MD, MBA, FCCM.

Contribution: This author helped write and edit the editorial.

This manuscript was handled by: Edward C. Nemergut, MD.

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REFERENCES

1. Itri JN, Yacob S, Mithqal A. Teaching communication skills to radiology residents. Curr Probl Diagn Radiol. 2017;46:377–381.
2. Ogunyemi D, Tangchitnob E, Mahler Y, Chung C, Alexander C, Korwin D. Conflict styles in a cohort of graduate medical education administrators, residents, and board-certified physicians. J Grad Med Educ. 2011;3:176–181.
3. Sevdalis N, Hull L, Birnbach DJ. Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress. Br J Anaesth. 2012;109 suppl 1):i3–i16.
4. Mitchell JD, Ku C, Diachun CAB, et al. Enhancing feedback on professionalism and communication skills in anesthesia residency programs. Anesth Analg. 2017;125:620–631.
5. Vasilopoulos T, Giordano CR, Hagan JD, Fahy BG. Understanding conflict management styles in anesthesiology residents. Anesth Analg. 2018;127:1028–1034.
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