Can I Cut You Open, Please?

I remember the day, almost 30 years ago, when as a nervous student, I handed an eminent neurosurgeon the wrong instrument by mistake. I recall even more clearly having to duck the bloody swab he threw in return and the ensuing stream of expletives that followed.

Such incidents were common place in the operating room (O.R.) back in those days. As students we all had our “war stories” and we vowed never to be as tyrannical, should we ever reach the dizzy heights of our learned mentors.

So, it was with interest, that I read a commentary in the July issue of Archives of Surgery showing that surgeon’s behavior in the O.R. affects patient outcomes, healthcare costs, medical errors and patient and staff satisfaction.  According to the article’s primary author, Andrew S. Klein, MD, MBA, a prominent liver surgeon and the director of the Cedars-Sinai Comprehensive Transplant Center, in our increasingly rude society where it is rare for a stranger to give up a bus seat to a senior citizen or a child to thank their parent for a meal, the lack of civility permeates even the surgical suite.

Often, surgeons get hired on the basis of their knowledge, training and technical accomplishments,” says Klein, “but operating rooms are social environments where everyone must work together for the patients’ benefit. When a surgeon, who is in the position of power, is rude and belittles the rest of the staff, it affects everything.”

Klein and co-author Pier M. Forni, PhD, cite numerous studies to demonstrate the links between rudeness in healthcare and how it affects patient care:

  • A study of 300 operations in which surgeons were ranked for their behavior shows a correlation between civility in the operating room and fewer post-operative deaths and complications.
  • Because co-workers tend to want to avoid a doctor who belittles them, 75% of hospital pharmacists and nurses say they try to avoid difficult physicians, even if they have a question about the doctors’ medication orders.
  • Hospitals with high nursing turnover generally have increased medical errors and poorer clinical outcomes.
  • One survey reports more than two-thirds of nurses are verbally abused by physicians at least once every three months.

During operations, surgeons cannot seek consensus on whether to employ staples or sutures. But it is bad medicine for them, for example, to berate a technician for wrongly handing them a clip if they, instead, have asked for a clamp, says Klein. Further, he states, once surgeons leave the operating room, they must understand the importance of relinquishing authority. By empowering others to lead, surgeons gain immeasurable respect among peers and subordinates; they create a culture of loyalty that surpasses what can be achieved via the strict, top-down management style that can be the typical persona of surgeons, Klein says.

Forni, founder of the Johns Hopkins Civility Project says two elements conspire to promote incivility – stress and anonymity. While surgery, by nature, is a stressful discipline, if surgeons took the time to know their co-workers better, it would help establish a positive workplace culture. That, he adds, translates into better patient care and outcomes, as well as higher job satisfaction for colleagues.

When people, especially team leaders, act rudely, Fomi says, “the stress response is activated, blood pressure increases and the body’s immune system is weakened. Studies show that incivility in the surgical workplace is associated with increased staff sick days and decreased nursing retention, both of which are associated with increased medication errors.”

Klein says that the steps to create a culture of civility in operating theaters must start early in surgeons’ formative years. The challenge for medical mentors of the next generation is how to nurture important traits in their charges of ego strength, confidence, focus, work ethic and dedication – without abandoning the practitioners’ commitment to civil behavior.

SRxA’s Word on Health could not agree more.  Thank you for reading!