With healthcare systems placing greater emphasis on improving safety and quality, efforts to gain a better understanding of possible threats to the delivery of reliable care are becoming increasingly important. Especially in surgery, reliable care depends on well-functioning teams that optimize communication and have mutual respect and continuous situational awareness within teams. “For surgical teams to function well, surgeons must model their behavior in a professional manner,” explains William O. Cooper, MD, MPH. “Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and therefore increase risk for medical errors and surgical complications.”

New Research

For a study published in JAMA Surgery, Dr. Cooper and colleagues assessed data from 2 academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. “We studied a large, geographically diverse population of patients to see whether reports describing rude and disrespectful behaviors on the part of the surgeon predicted an increased risk of complications after a surgical procedure,” adds Dr. Cooper.

Patients included in the NSQIP database underwent inpatient or outpatient operations at 1 of the 2 participating sites over a 4-year period. The authors looked at coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation and assessed data on postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation. The analysis included data on more than 13,000 patients who underwent operations by 202 surgeons. In total, 11.6% of patients experienced a complication, 6.0% of which were surgical complications and 7.8% of which were medical complications.

Findings & Implications

According to the results, the adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports when compared with patients whose surgeons had no coworker reports. Patients whose surgeon had 1 to 3 reports had an 18.1% higher estimated risk of complication and those whose surgeon had 4 or more reports were at a 31.7% higher estimated mean risk of complication when compared with patients whose surgeon had no reports (Figure). The differences remained significant in multivariable analyses that controlled for patient, operative, and surgeon characteristics, and in 3 different sensitivity analyses.

“Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation had a greater risk of surgical and medical complications,” says Dr. Cooper.  “These complications included surgical site infections, lung infections, and kidney complications.”

Based on the findings, Dr. Cooper says clinicians who are interested in ensuring the best outcomes for their patients should consider how best to interact with their teams so that they help create the most supportive, lowest stress environment. “Our findings also suggest that organizations interested in ensuring the best possible patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients’ risk for adverse outcomes,” he says. “How surgeons act as a professionals matters. Surgeons who bring ‘peace’ to the clinical environment are likely to create a culture that contributes to the best possible outcomes for their patients.”

More to Come

Future research efforts should assess whether improved interactions with patients, families, and coworkers by surgeons who receive interventions for patterns of unprofessional behavior also correlate with improved surgical outcomes for patients. “We know from other research that professionals who receive feedback about their unprofessional behaviors have a greater than 80% likelihood of improving their interactions with patients and coworkers,” Dr. Cooper says. “It would be fascinating to see if clinicians who change their behaviors after receiving feedback show a similar decrease in complications. We are also currently studying if unprofessional behaviors seen in clinician teams affect outcomes in clinical situations where interprofessional teamwork is crucial, including acute trauma.”