By its very nature, the operating theatre is a highly charged working environment. The name itself – theatre – recalls a history where an audience of students and spectators watched skilled surgeons perform life-changing work under a spotlight. The stakes are high, and tensions often run high too. A 2010 British Medical Journal article1 by Dr Rhona Flin revealed that two thirds of healthcare workers in operating rooms have witnessed rude behaviour. Under pressure, it’s very easy to speak with haste or judge harshly.

Profound impact

Yet if rudeness is an occupational hazard for surgical teams, it’s certainly not a benign one. Far from being quickly forgotten, rude remarks have been found to have a profound impact both on diagnostic and procedural performance. This summer, researchers at Tel Aviv University published a study2 that they hope will encourage greater awareness of behavioural norms in medical contexts.

The study involved a simulation in which 24 Neonatal Intensive Care Units from hospitals around Israel were brought together to treat a premature infant with necrotizing enterocolitis. The teams were informed that a US expert on team reflexivity would observe the simulation by live video feed and occasionally comment over a two-way link. Half the teams were given a ‘rude’ expert, who glibly commented that he was ‘unimpressed by the quality of medicine in Israel’, while the other half had a ‘neutral’ expert. Independent judges then scored the teams’ performance, information-sharing and help-seeking.

The results showed that a rude comment decreased performance by more than 50%, even in this exercise involving a hypothetical life-or-death situation. This profound effect came as a surprise even to the authors. In an interview with NY Magazine, Professor Amir Erez of the University of Florida commented: “We found consistently and dramatically that rudeness isn’t something people can easily get over… [rudeness] damages your ability to think, manage information, and make decisions. You can be highly motivated to work, but if rudeness damages your cognitive system then you can't function appropriately in a complex situation. And that hurts patients.”

​“A growing body of evidence suggests that a surgeon’s interpersonal skills directly impact patient outcomes.” 

Good behaviour gets results

The Tel Aviv University study3 is the latest in an increasingly compelling literature on how behaviour impacts medical performance. Writing in The Archives of Surgery in 20104, Dr Andrew S Klein, director of the Cedars-Sinai Comprehensive Transplant Center and the Esther and Mark Schulman Chair in Surgery and Transplantation Medicine, cited a study of more than 300 operations which showed the connection between civility in surgery and fewer postoperative deaths and complications. He wrote: "Often, surgeons get hired on the basis of their knowledge, training and technical accomplishments. But operating rooms are social environments where everyone must work together for the patient's benefit. When a surgeon, who is in the position of power, is rude and belittles the rest of the staff, it affects everything."

Focus on recruitment

With this in mind, is it time that the medical profession placed a stronger emphasis on interpersonal skills during the recruitment process? Recent developments suggest this evolution has already begun. In the UK, the NHS (the world’s fifth biggest employer, with 1.7 million employees) rates leadership and collaboration as key competencies in recruitment and performance measurement.

Meanwhile, the NHS and The Royal College of Surgeons of Edinburgh have for over a decade funded a multidisciplinary team of psychologists, surgeons and anaesthesiologists to create a Non-Technical Skills for Surgeons (NOTSS) framework5 – a behavioural rating system that assesses surgeons’ performance across four key non-technical skills: situation awareness, decision making, communication & teamwork, and leadership.

This skills taxonomy can be used to structure training and assessment, and it has already been adopted by the Royal Australasian College of Surgeons as part of their competence assessment and recommended by the ACGME (Accreditation Council for General Medical Education) for workplace assessment.

In the US, the Affordable Care Act, colloquially nicknamed Obamacare, made patient satisfaction a key measure of the quality rating of hospitals, resulting in a raft of new programmes designed to enhance EQ-related skills in medical teams. Writing on forbes.com6, Dr Thomas Chamorro-Premuzic, Professor of Psychology at UCL and Columbia University, highlights the example of the Centre for Creative Leadership – which has trained more than 400 healthcare institutions in collaboration and leadership – and the recruitment approach of leading centres such as the Mayo Clinic, NYU Langone Hospital for Joint Diseases, Rush University Medical Center, Thomas Jefferson, Cleveland Clinic and UCLA – all of which run personality assessments to help them to identify candidates who value team spirit and patient care.

As we witness this evolution in the working culture of the medical profession, it seems that empathy and civility will prove as important as scalpels and forceps in the surgical toolkit.

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