Disruptive, unprofessional behavior in the operating room (OR) environment has real consequences, both at the system and individual level—in particular, shifting attention away from the patient to the surgeon. “The responsibility to identify, report, and remediate disruptive behaviors lies with all of us, ” said Amalia L. Cochran, MD, FACS, Columbus, OH, co-moderator of the Monday, October 5, virtual Clinical Congress 2020 session Conflict in the Surgical Workplace: The Obstructive Surgeon.
The session will be available for on-demand viewing through the virtual Clinical Congress meeting platform through December 31.
Co-moderator Amelia C. Grover, MD, FACS, surgical oncologist specializing in breast and endocrine surgery and director of professionalism, engagement, and wellness, office of faculty affairs, Virginia Commonwealth University School of Medicine, Richmond, described the panel’s goal to address the patterns, behaviors, and solutions to this pervasive problem.
Dr. Cochran, associate professor of surgery at University of Utah Health, Salt Lake City, pointed out that negative behavior distracts from the patient, causes increased surgical errors, deters employment in surgery, and leads to diminished respect for surgeons. Patients who observe such behavior have a much higher rate of medical or surgical complication. “Coworker reports are even more revealing,” she said, indicating lower morale, decreased productivity, increased staff turnover, and mental health consequences. She enumerated coping strategies such as talking to colleagues, forming a support group, externalizing the behavior, avoiding bad actors, and warning others.
Nicolas C. Restrepo, MD, Winchester, VA, and Larry Harmon, PhD, Miami, FL, discussed the effects of counseling and coaching for physicians to help mitigate or prevent disruptive tendencies.
“We all went into medical school with good intent,” pointed out Dr. Restrepo, urologist and vice president, medical affairs, Winchester Medical Center. “It’s important to remember as we try to work through the challenges.”
He emphasized prevention when building a team—in particular, vetting prospective team members with alternative reference sources, such as talking to bedside nurses. He maintained that this is a quality improvement, rather than human resources, issue, and discussed PULSE 360, a feedback tool for preventive action.
Dr. Harmon, president, PULSE 360 Program, said that when addressing professionalism complaints, it’s helpful to shift from words like “disruptive” to more concrete behavioral words like “sarcastic,” “condescending,” “swearing,” or “yelling.” It also is helpful to identify the effects of the behavior, such as “The nurses are afraid to ask you important questions,” or “Your colleagues felt insulted.” He described AIM, a screening tool to assess an individual’s ability to change, and delineated initial professional interventions such as education, peer mentoring/support, collegial intervention, and coaching. 360, a high-intensity, anonymous assessment by colleagues, scored against national survey norms and coupled with coaching and education, has proved successful.
Anne C. Boat, MD, associate chief medical officer and director, fetal anesthesia, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, discussed obstructive physicians from the OR team member viewpoint. “Dysfunctional behaviors can disrupt even a good team,” she said, breaking down individual and team morale and trust. She cited a study that found that the most important element of a high-functioning team was psychological safety. Disruptive behavior creates a low level of psychological safety, she said, “so team members exist in the ‘anxiety zone’ rather than a learning zone—where they are reactive rather than proactive.”
Disruptive behavior doesn’t necessarily mean that someone is yelling or throwing an instrument across the room, Dr. Boat said. It can be demeaning or condescending speech delivered in a conversational tone. She added: “We know that disruptive behaviors lead to heightened anxiety and stress, which, in turn, affect memory, attention, judgment, and decision making, as well as adaptability. This, in turn, decreases situational awareness and reduces the ability of team members to respond rapidly to warning signals and to form a strong shared mental model. This affects patient safety and outcomes.”
Dr. Boat suggested several solutions, including education; a simple, easily accessible, retribution-free reporting system; prompt investigation by a neutral party; and defined institutional policies and procedures.
Co-moderator Noopur Gangopadhyay, MD, Chicago, IL, led the panelists in a discussion of how institutions may avoid dealing with behavioral problems because surgeons are high income generators. That attitude, Dr. Cochran said, fails “to account for the fact that any time that you have someone leave, you have the costs associated with retraining after you have recruited a new person. That person becomes a loss leader for you.”
The panelists underscored the importance of holding people accountable to an established code of conduct. Dr. Boat said, “The minute you deviate from that, you have destroyed the basis for the structure that you set up and what’s going to move your organization forward.”
Another associated cost, Dr. Harmon said, is that a hostile, harassing workplace environment can engender potential costly litigation.
The panel discussed groups that become complacent and accept dysfunction as the norm. “Behavior does matter,” said Dr. Harmon. “Just because it hasn’t caused an adverse event so far doesn’t mean it won’t. Statistically it probably will.”
The group also addressed the challenges of how cultural, gender, generational, and regional influences can affect how behavior might be interpreted as “normal.”