I remember as a surgical intern staring at the tan stain on one of the walls in our operating room. The stain, about the size of a fist and just slightly darker than the rest of the off-white wall, was legendary. The story goes that a surgical attending, in a fit of rage, threw a bottle of betadine at a resident. The resident, apparently light on his feet, dodged the projectile and the betadine bottle exploded against the wall behind him. Despite considerable efforts to wash it away, the resulting stain on the wall remained. I have never confirmed the veracity of the story, but it has an air of plausibility to it. I suspect everyone who works in an operating room can recall similar anecdotes or perhaps even direct experiences on this theme: Fear of the attending surgeon.
In more recent years, surgeons have generally evolved towards curbing openly aggressive behaviors, such as throwing objects and directing profane language at others. I'm not aware of specific data tracking how often surgeons make belligerent displays in the operating room, but my impression is they are less frequent now than they used to be. These behaviors are unacceptable and mechanisms for reporting and addressing these disruptive behaviors are increasingly more available [8, 9].
While openly aggressive behavior is easy to identify, passive-aggressive behavior is much harder to pin down. Because they are subject to personal interpretation, condescension and sarcasm are not easily reportable. But we all know the surgeon whose room nobody wants to be in. The idea of surgeons being tough to work with is certainly not novel, even among patients. And in the past, or even now, surgeons have gotten passes for their bad behavior: “I'm okay with my surgeon being a jerk, as long as he/she does a good job.” But should patients be okay with it? Should surgeons be okay with it? While being a condescending, sarcastic jerk won't make you the most-popular surgeon in the hospital, does it actually affect patient care?
Studies suggest it does [1, 5, 7]. While surgeons may justify passive-aggressive behavior as advocacy on behalf of the patient on the table, in fact there are negative consequences. It is difficult to communicate with someone who treats others poorly, especially if that person is in a position of authority. If a surgeon routinely makes people feel small with sarcastic retorts, why speak up? For example, if a surgical team believes that the patient's leg may be insufficiently padded, how likely are they to speak up knowing the surgeon will likely berate them if they are wrong—or worse, berate and dismiss them if they are right? In a hostile and tense operating room culture, the team is less likely to say something if they observe something concerning. As a result, communication is compromised—and compromised communication puts patient care at risk. According to the Joint Commission, 70% of all adverse events can be attributed to poor communication [2, 3, 5-7].
The evidence for this association is largely survey-based. There are no randomized double-blinded controlled studies examining the outcomes for nice surgeons versus jerk surgeons. Despite this lack of “quality” evidence, the connection between complications and surgeons’ poor communication skills with the team makes sense—it's intuitive. In any kind teamwork, excellent communication is critical for success.
However, all fear in the operating room is not necessarily a bad thing, depending on the situation. Traditionally, surgical training programs have employed a shame-based mechanism of learning. Fear of shame can be an effective educational motivator. During my residency, I trained with a world-renowned total joint placement surgeon. Affectionately referred to as “Dad” because he was an effective teacher, my attending was also notorious for being tough on the residents. “Dad” critiqued our knowledge base and surgical technique relentlessly throughout each case as we performed the procedures from start to finish (with his guidance). He would not hesitate to yell at us for errors in judgment. I remember feeling intimidated and anxious during these intense 2 months of training. He wasn't sarcastic or condescending; he was more directly critical. “No, no, no! You're doing this wrong! This is how you do it!” I studied extremely hard and prepared extensively during this rotation, in no small part because I didn't want him to yell at me. And though it was nerve-racking, the undisputable truth was that he was teaching and I was learning.
I don't believe that this educational pedagogy is the most effective manner of teaching and I don't embrace this method myself. However, I did come away from that experience feeling that his behavior was motivated by patient care and education. Despite the anxiety I felt in the operating room, I never felt inhibited to ask questions. There was no doubt that “Dad” was one of our most effective educators. Though our attending was tough on us, he was held in high regard, as evidenced by his nickname.
Nobody likes to be critiqued and yelled at, but it is important to recognize the motivation behind criticism. Criticism, given in good faith, should not be interpreted as disruptive behavior. Criticism, given in good faith, is essential for improving quality of care. Criticism, given in good faith, is absolutely necessary for education. So how does one define and assess “in good faith”?
The surgeon may regard the inefficiencies of the operating room, long turnovers, or a slow-to-respond team as unnecessarily detrimental to patient care. As a result, they may justify their condescending sarcastic behavior as “good faith” criticism in the best interests of their patients. Conversely, the surgical team may disagree and see the surgeon as being unreasonable, needy, and excessively impatient. Who decides if the surgeon is being a passive-aggressive jerk or earnestly acting in the best interests of the patient? As you may have guessed, it is not the surgeon.
Often, the surgeon is not even aware that he or she is regarded negatively. In general, surgeons are pretty smart people, but they may not be particularly self-aware, especially in the operating room. I once told a joke to my wife that that she didn't think was very funny. Incredulous, I told her that everyone in the operating room thought it was hilarious. She stared at me before it dawned on me: Surgeons may not be the best judges of how they are regarded by their own team. Institutional, anonymized, and protected assessment mechanisms can be helpful for fostering behavioral improvement. As surgeons, we often give feedback to students, residents, fellows, colleagues, and nurses. Just as they benefit from our honest feedback, we can certainly benefit from theirs. Just as we are always striving to improve our surgical technique, we should be striving to improve our team management techniques. Even “Dad”, as great as he was, probably could have benefitted from some of this feedback. We should seek feedback on how we can improve team dynamics. Unless we are really out of line, our nurses and techs are not going to pull us aside and give us constructive criticism. We need to seek this feedback. If one's hospital doesn't have such a process in place, mechanisms like the 360 Pulse Program (pulseprogram.com) may be helpful in getting it .
The operating room can be a stressful environment, especially when things go wrong. Most of us probably have acted badly with our surgical teams at one point or another. I know I have. But if we are going to act in the best interest of our patients, we need to better cultivate a more collaborative environment. Effective teams practice excellent communication. Hostile culture prevents team members from voicing legitimate concerns. The operating room does not function as a democracy, but it doesn't have to be an oppressive and authoritarian experience for the team. The operating room team doesn't necessarily have to be one big happy family, but at the very least, team members should feel free to speak up, especially when patient safety or quality of care is at stake.
2. Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg.
3. Cochran A, Elder WB. Effects of disruptive surgeon behavior in the operating room. Am J Surg.
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7. Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf.
8. The Joint Commission. Behaviors that undermine a culture of safety. Available at: https://www.jointcommission.org/assets/1/18/SEA_40.PDF
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9. Wyatt RM. Revisiting disruptive and inappropriate behavior: Five years after standards introduced. Available at: https://www.jointcommission.org/jc_physician_blog/revisiting_disruptive_and_inappropriate_behavior/
. Accessed October 28, 2016.