Surgeons' Misbehavior May Signal More Patient Complications

Lack of communication, respect, or regard for policies tied to worse patient outcomes




Patients of surgeons who were cited by colleagues for unprofessional conduct on multiple occasions were found to be at increased risk for medical errors and complications, a study of two geographically diverse medical centers found.

Among more than 13,000 patients under the care of 202 surgeons, those whose surgeon had at least 4 reports of unprofessional behavior filed against them by their coworkers had a significantly increased rate of any complication compared to those whose surgeon had zero reports filed against them (14.1% vs 10.7%, P<0.001), reported William Cooper, MD, MPH, of Vanderbilt University in Nashville, Tennessee, and colleagues.

Specifically, they had a significantly increased rate of any surgical complications (7.6% vs 5.8%, P<0.01) or medical complications (9.4% vs 7.1%, P<0.001), they wrote in JAMA Surgery, including more surgical site infections (7.4% vs 5.3%), cases of sepsis (4.4% vs 2.8%), pulmonary complications (3.8% vs 2.6%), and renal complications (1.1% vs 0.7%).

In the reports filed, unprofessional behavior was classified as unsafe care, a lack of respectful communication, falsifying schedules or other violations of integrity, and failing to follow policies or maintain other responsibilities.

"Our study makes the case that cognitive and technical competence alone are not sufficient," said co-author Gerald Hickson, MD, also of Vanderbilt University, in an accompanying audio interview. "The best surgical outcomes also depend on factors which promote strong functioning teams, sharing core values, knowing each other's roles, being able to speak up when concerns or uncertainties occur, and having respect modeled by all."

For medical professionals, a hostile workplace is "not uncommon in academic surgery departments," wrote Leonid Emerel, MD, of the University of Pittsburgh, and colleagues in an accompanying editorial.

In a prior trial involving neonatal intensive care unit teams, researchers found that groups randomized to work with a foreign expert that exhibited rudeness were worse at diagnosing and treating a condition than their colleagues who were assigned to work with an expert who provided neutral comments, supporting the idea that the presence of misconduct can have a negative impact on patient outcomes.

Although the editorialists noted that when a complaint is filed, it is important to presume innocence until the allegation is investigated, they emphasized that surgical care is based on a team effort and surgeons should take a "zero-tolerance approach" to unprofessional conduct.

"The study does not indicate the precise cause of the breakdown in patient care, but all surgeons can certainly recall scenarios that might serve as examples of the negative influence of unprofessional behavior on patient outcomes," Emerel's group wrote. "The present study highlights the specific interactions, including disrespect, disregard for hospital policies, and lack of availability to answer questions, that might reasonably be expected to have a negative effect on team performance and increase the risk for complications."

For this study, Cooper and his team identified electronic event reports that were filed by a surgeon's coworkers up to 3 years before the date of a patient's procedure. Coders manually analyzed the reports, which included examples of unprofessional behavior such as:

• "Dr ___ wiped the lens of the bronchoscopy scope on the bed sheets and then used the scope on the patient."
• "Dr ___ demanded, 'Who's the moron who has the patient in room 16?'"
• "Dr ___ instructed me to create false patients so it would look like the schedule was full."
• "Dr ___ refused to enter the electronic order after I described the verbal orders policy."

The 13,653 patients who underwent an operation in this study were followed for 30 days and monitored for surgical (site infections, wound disruption) and medical complications (pneumonia, sepsis, stroke).

More than three-quarters of the surgeries performed (76.6%) were general surgery, 8.1% were orthopedic, 6.2% were vascular, with smaller numbers for gynecologic, neurosurgical, urologic, otolaryngologic, cardiothoracic, and plastic surgeries.


Roughly 70% of the surgeons involved in the study were men. Women made up a higher percentage of the group of surgeons who had zero reports filed against them, "suggesting that women were less likely to generate coworker concerns than men," the authors reported.

Patients whose surgeons had more coworker reports tended to have higher American Society of Anesthesiologists (ASA) classifications, more often had contaminated wounds, and had longer average operative times.

One month after surgery, 140 patients died, 473 returned to the operating room, and 1,053 were readmitted. However, there was no significant difference observed between groups of patients whose surgeons had varying amounts of complaints filed against them and any of these outcomes.

Cooper and his team noted that a limitation to the study is that coworker reports are subjective and many may have gone unreported. The sample size was also "relatively limited," and the data was collected from two medical centers, so the findings may not be generalizable. Lastly, the data was not adjusted for individual surgeon volume or case mix, they noted.

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