On TV, operating rooms are a window into the perfect collaboration — surgeons, technicians, and nurses working seamlessly together for a common cause, the patient’s.

In reality, the focus of conversation is rarely on the patient. And the atmosphere is not always collegial.

A team of researchers at Emory University and Kaiser Permanente sat in on 200 surgeries at three different teaching hospitals, and logged each and every social exchange between clinical team members. What they discovered were complicated subcultures in which well-understood hierarchies and gender dynamics contributed to conflict — or helped alleviate it.

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Laura Jones, a medical anthropologist and the lead author on the new study, published in the Proceedings of the National Academy of Sciences, said her team was surprised by how distinct some operating rooms felt compared with others, each scene playing out differently depending on which actors were present.

“Just the culture [differences] between departments and between teams — you wouldn’t recognize that it was even the same endeavor,” she told STAT.

Jones and her colleagues found that the gender composition of teams was strongly associated with its level of cooperation. If the attending surgeon was of the opposite gender as that of most other personnel in the OR, cooperation was more common.

If the attending surgeon’s gender matched that of the majority of teammates, higher rates of conflict ensued. “You see more rivalry between same-sex colleagues,” said Jones.

A surgical team is made up of hodgepodge of medical staff — surgeons, nurses, anesthesiologists, technicians, physician assistants, medical residents, and students. Each individual has a defined role and place in the hierarchy, with the attending surgeon serving as the leader of the group. Conflict, the researchers found, was most frequently initiated down the hierarchy — from a higher-up toward an individual several ranks below.

In one case documented in the study, a surgical fellow gave a scrub nurse the kind of order that might be more likely to come from a bully on the playground: “You, me, parking lot!” (The nurse quit his job just days later.)

The degrees of conflict and cooperation also varied by specialty. Gynecological surgical teams showed the highest level of cooperative communication and the lowest level of conflict. On the other hand, cardiothoracic surgical teams showed the highest percentage of conflict, and the lowest cooperation.

Specialty differences, the study showed, cannot be considered in isolation from the gender composition of those departments. For example, over 95 percent of attendings observed in cardiothoracic surgery were men. Looking at roles other than the attending, orthopedic and neurosurgery teams typically had mostly men the OR, while gynecology departments staffed mostly women. With more men in the room, the probability of cooperation dropped — especially when the attending surgeon was a man as well.

Jones and her team spent thousands of hours sitting under surgical theater lighting, keeping a constant record in a special logbook known as an ethogram.

They documented a wide array of social behaviors: small talk, gossip, professional exchanges, teaching, insults, flirtation, and even dance, as the surgeons often played music while they worked.

“Much of what stresses them out is petty little things and interpersonal relationships,” Jones said.

Jones emerged from this project with greater empathy for surgical teams — she said she appreciates how exhausting their work can be, and understands that they need to socialize to pass the time. But sometimes, she said, her peek behind the curtain revealed a difficult-to-accept reality. “You want to think that everything is streamlined, and that nobody is discussing what they’re discussing while working on your loved one.”

Some researchers expressed concern with the study design.

Ethograms, a kind of specialized inventory, are traditionally intended for observing nonhuman primate groups in the field of ethology, the study of an evolution of a species. The use of the tool in this study could be problematic, said Jill Mateo, a behavioral ecologist at the University of Chicago and member of its Animal Behavior Research Group.

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Ethograms, she said, are supposed to be purely descriptive — documenting objective behaviors without any element of interpretation. In this case, however, Mateo said that the categories given in the ethogram — which include terms like “disintegrating,” referring to behaviors that threaten the function of the team — were not sufficiently objective. This ethogram, she said, is “interpretative, it’s functional, it’s making implications that we normally would not use in ethology.”

With the right ethogram, Mateo said, animal behavior methods can be applied to study humans. And despite her critiques of the study’s tools, she imagined that the findings would hold true with a more objective set of behavioral categories.

If that were the case, what lessons might be taken from the study?

In surgery, a high-stakes field that requires both technical and interpersonal skills, conflicts can be problematic for teamwork and can even threaten patient safety. But conflict isn’t all bad — as Jones said, team members need to feel comfortable calling one another out if there are problems. Jones and her co-authors refer to the theory of the “magic” ratio of cooperation to conflict, a 5:1 balance between positive and negative interactions. This ratio has been proposed in the context of successful marriages, and the researchers imply that, similarly, some degree of conflict is likely healthy in the OR.

Still, the study’s authors said, the interpersonal aspects of cooperation and conflict need to be addressed early in medical careers. They proposed greater interprofessional training for starters. And Jones said medical schools can do better to identify “certain relationships and which ones tend to be more volatile in medicine.”

Moreover, she said, surgical departments should encourage more mixed-gender teams.

A few more female neurosurgeons couldn’t hurt.

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  • A very interesting article. All members of the cardiac team should be taught to and allowed to “speak to their concerns”! After 50 years in cardiac surgery, I have been witness to many different team cultures. The negative ones ALWAYS had one key element: an egotistical surgeon who was always empirical! That one characteristic is a negative wither a male or a female surgeon!! A healthy and productive team should process the following: Professionals, within an organized and healthy team culture, know exactly where they should fit and would know their professional accountabilities within their individual and intended scope of practice. A healthy and productive culture, within an organized cardiac team, is a pleasant experience for all, especially your patient. Any disturbance within the Force or unhealthy team culture (Together Everyone Accomplishes More) – acronym for TEAM – would/could have a negative effect on overall cardiac patient care. Speaking to your concerns might just be the secret? If you should choose to complain and not discuss your reality and/or concerns, you are a contributor to an ongoing unhealthy culture! As such, the emperical surgeon is being allowed to continue to contaminate your team culture! Human Resources (Hospital Policy) can be of assistance in following an organized approach to your concerns! If not you, then who to speak up for the patient, the silent recepient of your care.

    • I apologies for not having including my professional identity nor occupation. I am a retired Clinical/Cardiovascular Perfusionist who entered the profession in 1968. Although recently retired, I remain very much interested in the domain of a “healthy cardiac team culture or environment”. Having said that, I have occasionally been involved in a less than desirable negative team culture which, as a result, demanded that I should speak to my concerns – even for others less inclined to do so. As Chief Perfusionist in a large academic setting, it was incumbent on me to address these concerns and to also speak to the concerns of my staff. The outcome resulted in the few arrogant surgeons involved continuing to bully those who would allow it to continue. The desired result with a considerable reduction in bulling towards the Perfusionists who spoke to their concerns. No PERSON in the OR has the right to bully, demean or insult other members of the cardiac team – NO PERSON! The author mentions an organized and coordinated empirical culture which would allow each team members to exercise his/her autonomy with a desirable and respectful result – the surgeon being in charge overall. This healthy team scenario is the desired reality especially in a high stress emerg/urgent cardiac case where every minute counts in saving a cardiac patient. Thank you, Jim

  • Having worked in the OR in both large academic centers and busy private practice hospitals, the dynamic described is NOT what I have experienced for the most part. The only thing in the article that rang true, is cooperation in OB/GYN ORs because everyone understands that the welfare of the patient is the only thing that matters. That includes administration, usually.

    Otherwise, my experience in large academic centers is that surgeons are often allowed to bully everyone in the OR because administration sees surgeons as bringing money to the facility and everyone else in the OR is merely a serf working for the surgeon.

    As a female anesthesiologist with 26 years of experience, there are nice surgeons of both genders and there are jerks of both genders. The best cooperation comes from surgeons playing nice in the sandbox. The best patient care often occurs with nicer surgeons as well because no one feels pressured to do things that might turn out to be stupid.

    There are fewer female anesthesiologists than female surgeons. I suspect it because you have to have very thick skin to deal with the demeaning actions/words of many surgeons. I have been pushed, picked up by my scrub top, cursed at in front of patients, belittled by surgical residents who’ve been taught to be bullies by their attendings, demanded by surgeons to do things that would be harmful to the patient, etc. But I did several years of surgery before changing over to anesthesiology. So I know their tactics are meant to bully me into supplication. Since my personal agenda is to give the patients optimal care, I don’t cave in to stupidity.

  • As an anesthesiologist, I have studied and lectured on the first anesthetic demonstration by W.T.G. Morton at the Massachusetts General Hospital in October. 1846. I find the operating room dynamics, brought out by this study, amazingly similar, so many years later.

  • camera’s in ALLL O.R.S…….make them mandatory!!!!!My case and several others would of been saved a lot of forced physical pain had a camera been in the o.r.My surgeons exact words after surgery was,,”Your internal organs are badly beaten up,,your gallbladder was completely*calcified,and looked like a dam gravel pit,,pancreatits,,,all ducts were closed,,open them all up,,cleaned everything out.It was a mess in there ,un-quote,””…His o.r. report was the complete opposite after he found out 3 different prominent hospitals/doctors label my upper gastric pain in my head/This surgeon outright lied,,,,tamper’d w/my medical records,,,to lie for Doctors at Mayo,Rochestor…St,Lukes Milwaukee,,,,and now his Hospital St.Marys/He was not only a surgeon,,but the Medical Director and on the Insurance Board,,,When my primary and pain doc ask for a repeat laparoscope to prove his lies,,conveniently he denied 3 request,,,,although he preform 95% above the average surgeon the # of laparscope.The nurses were thee only 1ns telling me the truth a t this point,,it takes years for a organ to calcify,,packed w/stones.,,and a lipase of 1500 is very bad!Soo camera’s in all o.r.,,,,that way patients can get the medical care they deserve,,,not a bunch of liars playing god,,,,,,,

  • Actually conflicts are common in TV representations. This sells ratings and advertisement as also seen in the negative title and headers in this piece. The dramatic is emphasized in title and headers. This negates reporting of an important study.

    Nice review of the article – especially the limitations. The researchers did indicate that they got what they were looking for as part of the analysis. Qualitative studies are plagued with such bias but are important to help understand relationships. It appears that the emphasis reported was on the attending also rather than other interactions.

    It appears that the situation with regard to the patient condition is not being considered. Stressful surgeries change the entire environment. Cardiovascular situations and trauma can be critical as are patient conditions. There is a difference between terse, command voice of human beings reduced to backup mode and cooperative exchanges when all is going well.

  • This is a great and timely article. Please keep sharing more about the real world surgical environment.

    • Amen Lynda,,,after 17 years,,at least 6 different hospitals,,sticking w/2 primarily,,I have forcible seen my share of Doctors,,Now I know they wont like this,,but from 1 patient view point,SOME ,,Doctors have got to be thee biggest infants I have ever met..the ones I have met,,,so-far 1 ,,only 1,,out of about 40 doctors,,,has been mature,,,I have found if they screw-up,,like never even testing for 16 years a lipase level or never ever doing a ultra sound,,automatically labelling it in my head as a women,,boy,,when they got called out for their major screw-up,,they down play it big time,,or they literally tamper’d w/my records,,deleting items,outright lying on others,,especially those pertaining to my pancreas..ALL OF SUDDEN a once tumor in the thoracic spine,,big enough to do a complete lamectomy for thee entire thoracic,,the tumor,,turns into a cyst,,and the surgeons report gone.Just the mri,,which did show it smaller,,but by the time the surgeon got in,,it a tripled in size,,Or a lower lope lung collapse,,,turn into somehow my fault,,Point being,,as laymen we are raised to believe doctors are honorable,,,non-liars,,,ethical,,,moral,,everything good,,,is what u were told Doctor represent,,by our parents,hell everyone,,,BOY OH BOY,,, that is the farthest from the truth our parents told us,,,just as bad,,when u find out there is no Easter Bunny,,lol,,,maryw

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