On June 19, 2019, the article, "Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients" (William O. Cooper, David A. Spain, Oscar Guillamondegui, et al.), was published in JAMA Surgery.
Dr. Todd Rosengart describes the article findings, what they mean for the cardiothoracic surgery specialty, and his view on the topic of unprofessional surgeon behavior and its impact on patient complications.
How Unprofessional Surgeon Behavior May Impact Patient Complications
Leading by example is one of the basic tenets of good leadership and team management. Based on lessons from the aviation industry, modern thought suggests that an essential component of a well-performing, highly reliable organization is a just culture in which all team members effectively contribute to the team mission. This type of culture in health care may help ensure the well-being of patients by minimizing complications and errors. What happens then if the team leader or the “captain of the ship” does not properly model appropriate team behavior in supporting a just culture?
In an intriguing recent report on this subject by Cooper et al. published in JAMA Surgery, data suggest surgeons who may not perform well as team members appear to undermine the quality of surgical care. These findings came through a retrospective review of the clinical results of 13,653 patients who were treated by 202 surgeons practicing at two prominent academic medical centers over from 2012 to 2016. The patients underwent a broad range of procedures ranging from orthopedic to cardiothoracic operations.
The investigators found a significant increase in the 30-day operative complication rates, as reported in the American College of Surgeons National Surgical Quality Improvement Program, for surgeons with a higher number of unprofessional behavior reports in the preceding 36 months versus those without unprofessional behavior reports. These unprofessional behavior reports included concerns about poor or unsafe care, clear and respectful communication, integrity, and responsibility. Compared to a mean of 1.3 reports, surgeons in the highest report group had a mean of 6.1 reports. If these data accurately depict an association between “poor surgeon behavior” and increased complication rates, this is a profound and startling validation of the influence of the surgeons’ behavior on group dynamics and ultimate clinical outcomes.
Compared to an overall complication rate of 11.6% in this study, surgeons with 1-3 unprofessional behavior reports were found to have an absolute complication rate of 12.6%, and those with 4 or more reports had a complication rate of 14.1% (P <0.001). This rate difference held true after multivariate analysis considering patient, operative, and surgeon characteristics, with an estimated risk of complication that was 18.1% higher for surgeons with 1-3 reports and 31.7% higher for surgeons with 4 or more reports compared to surgeons with no reports. Similar outcomes were found after sensitivity analyses for surgeon years of experience and study site.
What happens then if the team leader or the “captain of the ship” does not properly model appropriate team behavior in supporting a just culture?
It is enticing to treat this association as evidence that “good team play,” which could provide robust team communications and feedback on patient status, is an essential component in the optimal delivery of surgical care. On the other hand, this study is potentially limited in that the absolute differences between “good” and ‘bad” surgeons is quite small (10.7% vs. 14.1% for surgeons with 0 vs. ≥ 4 reports, respectively) and the limited risk analysis available for this quite heterogeneous group of patients does not allow analysis of alternative potential associations. For example, the “poor behavior” physicians were noted to have higher risk patients (as exemplified by ASA Class 3 or 4 status), suggesting that the behavior of these surgeons also may reflect traits associated with a higher level of surgeon competency that attracts higher risk patients. Such an association would still not preclude the even more desirable state, however, of a skilled and well-behaving surgeon. Presumably, the latter would only enhance the opportunity for well-functioning team dynamics.
Finally, one additional interesting aspect of this analysis was the greater percentage of surgeons with unprofessional behavior reports who were men compared to women: those with 1-3 reports were 76% versus 63%, and those with ≥ 4 reports were 16% versus 9%, respectively. These data suggest that we look to our female colleagues when we model #lookslikeasurgeon.
Todd K. Rosengart, MD, is a Cardiothoracic Surgeon at Baylor College of Medicine and serves as Professor and Chairman of the Michael E. DeBakey Department of Surgery at the Baylor College of Medicine, as well as holds the DeBakey Bard Chair of Surgery. He also is the Chair of the STS Workforce on Media Relations and Communications.