Speaking Up: Strategies on Handling Disruptive Behavior

Speaking up is still too hard to do in surgery, according to a panel of surgeons who presented at the 2022 Clinical Congress of the American College of Surgeons.

The six surgeons on the panel, and several in the audience, called for a culture change in the profession, asking surgeons to set up programs—formal and informal—that encourage team members to speak out about troublesome acts committed by their colleagues and to protect whistleblowers.

Institutions need clearly defined mechanisms for action when people discriminate or cause other kinds of harm, according to the panelists. Surgeons are more inclined to speak up when they know their voices are likely to lead to positive change, they said.

At least 90% of clinicians have been exposed to disruptive behaviors—such as harassment, sexism, racism or bullying—in the OR, one study showed (Curr Opin Anaesthesiol 2018;31[3]:366-374). But these events are rarely exposed. An international study found disruptive behavior in the OR was underreported by 96.5% of respondents (Can J Anaesth 2020;67[2]:177-185).

“It’s really the collective responsibility, not only of the leaders and stakeholders but every single one of us here in the room, and at home, to create an environment where it is safe to speak up,” said Erica Mitchell, MD, MEd, a professor of surgery and the chief of vascular and endovascular surgery at the University of Tennessee Health Science Center, in Memphis.

A Culture of Silence

Carter Lebares, MD, an associate professor of surgery at the University of California, San Francisco, told the audience about a stressful encounter with an attending during her residency. When a patient’s port site would not stop bleeding at the end of a minimally invasive operation, the attending grew frustrated and said to the team in the OR, “Jesus Christ, this is positively vaginal,” Dr. Lebares recalled. The attending asked the fellow to put a finger in to stop the bleeding while making a graphic, sexually inappropriate comment.

Dr. Lebares was shocked and unsure of what to think. “Immediately, I had to figure out how to readjust my sense of what it meant to be part of this team. I did that because I wanted to be part of this team. It mattered to me to belong,” she said.

She told the audience that she was sharing the story to illustrate how trainees and surgeons are forced to adapt to the existing professional culture, even if they are uncomfortable.

She said the culture of silence around misbehavior also leads to situations like the controversial 2011 Valentine’s Day editorial in Surgery News in which Dr. Lazar Greenfield, then president-elect of the ACS, claimed semen had mood-boosting effects on women during unprotected sex. He later resigned from his ACS post.

Citing work from University of Toronto surgeon and researcher Carol-Anne Moulton, MD, Dr. Lebares said surgeons and trainees feel pressured to fit into the fellowship of surgeons through a long-standing tradition of rewards and penalties. They first internalize the professional ethos and then demonstrate their solidarity by adopting widely accepted behaviors, even if that includes mistreatment of others.

Surgeons who adapt to the cultural norms of a place excel and those who do not will struggle. This makes it difficult for surgeons to speak out without damaging their careers, she said.

Surgeons are known for being disciplined, assertive, indefatigable, confident and driven—traits that can be positive but also contribute to a hostile work environment, she said. Assertiveness can turn into bullying and confidence into egotism.

Dr. Lebares said surgeons should work to preserve behaviors that benefit patients and co-workers but get rid of patterns of mistreatment. She urged surgeons to place higher value on intellectual humility and emotional intelligence. There should be zero tolerance for disruptive behaviors, she said.

She also advised institutions to train bystanders to speak up. Leaders must promote a culture of psychological safety, she said.

“Our culture can evolve to keep the things that are beautiful but create something that is better for our patients,” she said.

Consequences of Speaking Up

Dr. Mitchell said surgeons could learn from the experiences of whistleblowers in surgery and other professions.

She reviewed the literature on whistleblowers and found that most people do not report problems because they fear reprisal, or they believe disclosure will not make a difference.

When employees face an inappropriate situation, they typically have three choices—stay silent, leave or voice their discontent—she said, citing a report titled, “The Sound of Silence: Whistleblowing and the Fear of Reprisal” from Canada’s Office of the Public Sector Integrity Commissioner. Most choose the first option because the consequences of speaking up are significant. People worry about being ostracized, isolated or excluded from important work projects. They fear they will lose their job or be blacklisted.

People who are likely to speak up have more experience, are in a senior role or are high performers, she said. Because of their standing, they have more credibility and are harder to silence within an institution.

“In a sense, you’re in a privileged status set. You’re in a position where you can drive change forward and influence the people around you,” she said.

People who are from individualistic cultures, score higher on extroversion or are less agreeable by nature are also more likely to speak out.

People at all points in their career feel more comfortable speaking up when strategies are in place to protect employees who voice criticism, she said. People need to feel safe expressing their concerns, and they need clarity around disclosure, knowing who they should report to and how the chain of disclosure works, she said.

Reporting programs should incentivize fairness, not just reporting, and they need clear policies about what will happen in response to a report, she said.

Dr. Mitchell concluded with a quote from Jane Goodall: “What you do makes a difference. You just have to decide what kind of difference you want to make.”

She added that speaking out takes “grit, perseverance and passion. It takes courage to move the needle. But know that challenges will be overcome.”

Disruptive Behavior in the OR

Mansi Shah-Jadeja, MD, an assistant professor of thoracic surgery at the University of Kentucky, in Lexington, opened her talk by asking the audience to raise their hands if they had been exposed to disruptive behavior in the OR or been the perpetrator. Nearly everyone present responded. “That fits with what we see in the literature,” she said.

People define inappropriate behavior differently, she pointed out. In a study of Italian surgeons and OR nurses, surgeons reported the OR environment was supportive and home to exemplary teamwork, while nurses saw violations of safety rules and procedures (Work 2014;49[4]:669-677).

She said surgeons need to keep in mind that they are the “ringleaders” for a team of people in the OR.

“We’ve got medical students, residents, nurses, anesthesia staff, support staff, vendors and advanced practitioners, surgical techs, and the patient as well,” she said.

The ORs are inherently stressful environments, she acknowledged. But surgeons can set the stage from the outset by empowering people to speak up, she said. Before an operation begins, Dr. Shah-Jadeja addresses medical students by their names and encourages them to ask questions. After surgery, she’ll sometimes query the students whether they felt comfortable asking questions in the OR. “That’s usually met with mixed responses,” she said. Students often tell her they feel more comfortable when they see other people asking questions.

She tells residents and students in advance of an operation about things she expects to be stressful. She reminds them to communicate with her whether they see changes in the patient or other things that worry them.

In her department, medical students are asked to nominate attendings and residents who are outstanding teachers and explain what makes them exemplary.

The department also instituted a QR code whereby residents can anonymously report concerns to program directors, she said.

Pay Gaps

Nasim Hedayati, MD, MAS, a professor of surgery and the medical director of the UC Davis Vascular Center, in Sacramento, Calif., addressed the long history of gender discrimination in medicine. Discrimination and harassment of women contribute to a higher attrition rate in medicine, with nearly 20% of women choosing part-time positions or leaving medicine altogether within six years of residency (JAMA Netw Open 2019;2[8]:e198340). In healthcare, women earn between $0.72 and $0.96 for every $1 paid to men, according to the Association of American Medical Colleges 2019 compensation data. The gap exists even in specialties or departments where women account for the majority of practitioners.

For adults with professional degrees, the gap in income widens over a career to the point where, over a lifetime, men earn $1.6 million more than women based on data from the U.S. Census Bureau.

Dr. Hedayati said the pay gap results from an opportunity gap: Women receive less administrative and clinical support staff, and they’re more likely to be assigned unpaid work or institutional housing tasks. Even in a fee-for-service system, male surgeons earn more than women across every specialty (JAMA Surg 2019;154[12]:1134-1142).

“Pay is the clearest indication of whom an institution values,” she said.

She said surgeons need to be alert to various types of discrimination and provide support and opportunities for female surgeons, including active support from men to leadership positions.

All panelists urged surgeons and residents to document instances of disruptive behaviors and speak to colleagues to see whether an event reflects a recurring problem. “You want to make sure that you’re protecting not just yourself but other residents to whom it happens to,” Dr. Hedayati said.