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Incivility in Surgery

Author Information (click to view)

Andrew S. Klein, MD, FACS, MBA

Director, Comprehensive Transplant Center
Chair in Surgery and Transplantation Medicine
Cedars-Sinai Medical Center

Andrew S. Klein, MD, FACS, MBA, has indicated to Physician’s Weekly that he has no financial disclosures to report.

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Andrew S. Klein, MD, FACS, MBA (click to view)

Andrew S. Klein, MD, FACS, MBA

Director, Comprehensive Transplant Center
Chair in Surgery and Transplantation Medicine
Cedars-Sinai Medical Center

Andrew S. Klein, MD, FACS, MBA, has indicated to Physician’s Weekly that he has no financial disclosures to report.

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Incivility can lead to social isolation or exclusion, the devaluation of someone else’s work, verbal threats, and even physical confrontations. The costs associated with incivility in the OR can be substantial.
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Hospitals and medical centers are increasingly beginning to appreciate that disruptive behavior in the operating room (OR) is a problem deserving of serious attention. The costs associated with incivility in the OR can be substantial, oftentimes leading to increased staff sick days and decreased nursing retention, both of which are associated with medication errors. Exposure to incivility among surgeons often begins in their formative years. Frequently, perpetrators of belittlement or harassment are residents, fellows, and clinical professors, the same people who serve as role models for the next generation of physicians.

The Perils of Incivility in Surgery

Incivility can lead to social isolation or exclusion, the devaluation of someone else’s work, verbal threats, and even physical confrontations. Furthermore, research shows that rude behavior is bad for both mental and physical health. Conversely, other studies have demonstrated that civil behavior within the workplace can lead to a “helper’s high,” in which others in the OR feel empowered and contribute to improving outcomes in the patients they treat. The challenge for those entrusted with teaching the next generation of surgeons is to nurture the important surgical traits of ego strength, confidence, focus, work ethic, and dedication without forgetting the need to be committed to being civil to each other. Surgeons are people in the position of power who are typically hired on the basis of their knowledge, training, and technical accomplishments. ORs, however, are social environments where everyone must work together for the patients’ benefit.

Fostering Civility in Surgery

To establish a positive OR culture, increased emphasis should be placed on non-technical skills, such as leadership, communication, teamwork, and situational awareness. By not insisting that we make all the decisions and by empowering others to lead, we can gain respect and loyalty among peers and subordinates. A “top-down” management strategy was prevalent among surgical leaders 20 or 30 years ago, but this approach is now out of style. There are three key strategies for improving the behavioral culture in ORs:

1. Recognize the power of civility. Civility has the potential to improve the surgical workplace, patient outcomes, and workers’ quality of life. Developing a clear, consistent code for all staff—regardless of stature within the organization— is paramount.

2. Eliminate anonymity. To foster civility, the staff needs to know each other. The rewards from becoming acquainted with coworkers are substantial. As anonymity dissipates, it’s less likely that rude behaviors will be initiated or accepted. Minor disagreements can stay minor rather than escalate into damaging conflicts. When recruiting staff, trainees, and faculty, assess social skills and personality traits that will nurture a culture of civility.

3. Get leadership “buy-in.”Administrative leaders should help model the behavioral culture for the team working in the OR. The training methods used to shape the next generation of surgeons should encourage the advancement of knowledge and the promotion of good surgical judgment while keeping a keen eye on commitment to civility.

A Great Opportunity

The surgical community has an incredible opportunity to lead a civility initiative in healthcare. We must remember that today’s victims are tomorrow’s bullies. Developing a fair and consistent universal code for surgeons, nurses, staff, and administrators to foster civility in the OR can yield substantial dividends, promoting trust, respect, and loyalty while also creating a positive working environment that is safer and more efficient for the patients we treat.

Readings & Resources (click to view)

Klein AS, Forni PM. Barbers of civility. Arch Surg. 2011;146:774-777. Available at: http://archsurg.ama-assn.org/cgi/content/full/146/7/774.

Waisel DB. Developing social capital in the operating room: the use of population-based techniques. Anesthesiology. 2005;103:1305-1310.

Kerfoot KM. Leadership, civility, and the ‘no jerks’ rule. Urol Nurs. 2008;28:149-150.

Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005;105:54-65.

Kivimäki M, Elovainio M, Vahtera J. Workplace bullying and sickness absence in hospital staff. Occup Environ Med. 2000;57:656-660.

Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678-685.

2 Comments

  1. I am a surgeon. I have worked in large academic teaching hospitals, large private hospitals and in small community hospitals. By and large, nearly every busy practicing surgeon that I have ever worked with, or known about, is uber-focused and intense about what they are doing before, after, and especially while they are in the operating room. Performing surgery, even a “minor case” requires an extraordinary level of continuous concentration for the duration of that case. What is commonly referred to as “disruptive behavior” of the surgeon is most often a response to something going on in the environment of the Operating Room that interferes with the surgeon’s ability to focus or concentrate or to obtain the needed help to complete the operation successfully and in a timely manner. To single out and LABEL “the surgeon” as “disruptive” is to essentially hold all others in the operating theater harmless, which is hardly true. The article above is trying to get at this issue by adopting a “Code of Civility” for everyone working in the Operating Room, and I applaud that effort. I have worked with many, many excellent nurses, surgical technicians, anesthetists and anesthesiologists. Occasionally, one of these professionals will act unprofessionally, and will forget the importance of what they are doing, or become bored with what they are doing. Some will talk unnecessarily and ad nauseum during the operation about when they are getting off, who is on call, who is going to have to stay past 3:00 p.m., getting their tires rotated, and where they are going, or have been on vacation, many times without any visible or conscious effort to keep up with and understand what is going on “on the field,” i.e., inside of the patient’s body. I have actually had to SHOUT, yes, “SHOUT!!!”, that “THERE IS UNCONTROLLED BLEEDING!” in order to get the attention of the team to come back to what is going on on the Operating Room table, i.e., in the patient. Is the shouting disruptive, or is the environment that made the shouting necessary the real disruption? Sometimes my co-workers in the Operating Room will be unprepared or inadequately trained to do the job they have been assigned to do, being sent into that environment by administrators who sometimes treat them as if one warm body in a given category is as good as the next, which is not true. All of the situations listed above are truly “disruptive.” Disruptive to the surgeon’s ability to concentrate and to perform, and disruptive to the care of the patient. It is not enough to just “get to the end of the case.” Each and every operation must be performed in a superb manner and completed as quickly as possible. This requires exceptional focus and concentration by EVERYONE in the room. Anything that interferes with that being possible, is “disruptive.” As we move forward, and we should, to defining the parameters of “civility” in the Operating Room, I would encourage everyone to look at all of the potential behaviors and attitudes that “disrupt” optimum care of the patient, and every- and anything that has even the tiniest possibility of having a negative influence on the outcome of the surgical patient. Of the Operating Room team, it is the surgeon who will be explaining the outcome to the patient’s family, and seeing the patient the next day, the next week, and beyond.

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  2. As a Transplant Coordinator in the Chicago area, I worked w/heart surgeons in the OR who were consumate professionals. I have, however, worked w/my share of brats. My personal philosophy was no tolerance for bad behavior, unfortunately, that took a tremendous toll on me, personally. Standing ground and not flinching when a surgeon got right in my face to scream at me was so very difficult. The next step was even harder: telling them in a quiet, controlled voice that their behavior was not acceptable and I would not tolerate it. On one occassion, it required a trip to the broom closet for a more heated “come to Jesus” talk. I was good at what I did, so respect from the rest of the surgeons and staff came easily. Bratty surgeons came around after a confrontation. It was just such an ordeal to have to go through it each time and I felt compelled to stand up for the nurses who didn’t have the where with all to stand up for themselves. Joan of Arc, anyone? There’s another component to this, which you didn’t mention: hospital administration who treat surgeons like precious commodities when they are really precocious toddlers. A surgeon may have carte blanche to behave badly and if he or she complains about a nurse, that nurse will take the heat.

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