Senior Surgeon's Behavior Affects Trainees' Willingness to Communicate

By James E. Barone MD

August 19, 2014

NEW YORK (Reuters Health) - When surgeons encourage questions, medical students are more likely to speak up if they notice errors in the operating room, a new trial shows.

Researchers found that 82% of trainees who had been encouraged to ask questions before a simulated surgery challenged a surgeon who deliberately told them to commit an error. Only 30% did so when they had been discouraged from questioning the surgeon.

"On our labor and delivery unit, we had started to encourage our surgeons to say, 'Speak up if something does not look right to you' during the time-out, and we've had amazing positive feedback," said senior author Dr. Nelli Fisher of Maimonides Medical Center in Brooklyn, New York.

"It is unbelievable how one genuinely spoken sentence can create an atmosphere of comfort and camaraderie," she told Reuters Health by email.

The findings, online July 25 in the Journal of the American College of Surgeons, surprised Dr. Hilary Sanfey, who has studied communication in the operating room.

Dr. Sanfey, professor of surgery and vice chair for education at the Southern Illinois University School of Medicine in Springfield, said she would have expected students not to assert themselves, particularly in an OR setting.

"Our second-year students participate in a simulated patient interaction session in which they are handed lab results for a standardized patient with an incorrect name," she told Reuters Health by email. "Most students do not notice the error or if they do they still don't say anything even though the lab results show a critical potassium level."

For the trial, second- and third-year students being oriented to their obstetrics and gynecology rotation were taught a simple laparoscopic surgical technique, which was to always cauterize tissue before cutting it.

Before each student scrubbed with an attending surgeon, those randomly assigned to the "discouraged" group (n=27) overheard the surgeon say she was very busy and in a hurry as part of the study. The surgeon also told them to save questions for another time.

Students in the "encouraged" group (n=28), were greeted warmly by the surgeon and told to speak up if something did not look right.

At some point during a simulated salpingectomy, the surgeon instructed each student to cut a structure before cauterizing it. If students refused to follow the command or questioned the surgeon, they were judged to have spoken up.

The students who had been who had been encouraged to ask questions were significantly more likely to balk at the error (23/28 vs. 8/27; p<0.001).

To control for baseline personality characteristics, two different personality tests were given to all students. The personality profiles of the discouraged and encouraged groups did not differ significantly, nor did demographics such as age and sex; the personality profiles of the students who spoke up vs. those who did not were also similar.

The authors felt that since both groups had similar personalities, the decision to speak up was more likely influenced by the environment created by the surgeon's attitude.

Convincing "old-school" surgeons to encourage speaking up might not be easy. "Changing to a system where everyone is free to speak up without fear of retaliation will undoubtedly take time," said Dr. Fisher.

She added that simulation might help because it is a safe environment where a surgeon may feel more comfortable, more receptive to questions, and better able to reflect on the value of accepting team members speaking up.

"I think it might be best to focus our energy on the surgeons of tomorrow," offered Dr. Sanfey. "A challenge is getting residents and students to take what they have learned in the simulation lab to the OR and getting attendings to understand and encourage speaking up."


J Am Coll Surg 2014.


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