Reports of unprofessional behavior align with increased risk.

A report in JAMA Surgery has identified a unique threat to patient safety and health care quality: unprofessional surgeons.

Using data from the National Surgical Quality Improvement Program (NSQIP), researchers found surgeons with reports from coworkers about unprofessional behaviors place their patients at greater risk for complications. The research team included William Cooper, M.D., vice president for Patient and Professional Advocacy at Vanderbilt University Medical Center.

As care team leaders, surgeons set the tone in the OR, Cooper said. “Surgical teams require every team member to perform at their highest level. We were interested in understanding whether surgeons’ unprofessional behaviors might undermine culture, threaten teamwork and potentially increase risk for adverse outcomes.”

Identifying High-Risk Surgeons

The retrospective study included data from 13,653 patients who underwent inpatient or outpatient surgery performed by 202 surgeons across two academic medical centers (at Vanderbilt or Stanford). Most patients (76.6 percent) underwent general surgical operations.

Coworker reports about professionalism were collected from hospital safety-reporting systems and the NSQIP database. The reports spanned four validated categories: poor/unsafe patient care, communication issues, integrity, and taking responsibility. The data did not contain surgeon identifiers.

The researchers linked coworker reports from the three years prior to each case to peri- and postoperative complications. In total, the cohort included 825 surgical (6 percent) and 1,070 medical (7.8 percent) complications, occurring up to 30 days post-surgery.

Rising Complications

On average, patients whose surgeons had one to three reports of unprofessional behavior were at 18 percent higher estimated risk of experiencing complications, and those whose surgeons had four or more reports were at nearly 32 percent higher estimated risk, compared to patients whose surgeons had no reports.

Patients whose surgeons had a greater number of coworker reports were more likely to have surgical site infections and were at greater risk for sepsis, as well as pulmonary and renal complications. There were not significant differences in patient readmission, reoperation or mortality.

Said Cooper, “A surgeon’s behavior toward their coworkers directly influences patient outcomes.”

Leading Sustainable Change

Patient complaints about a surgeon’s behavior are a marker for adverse outcomes, but the study provides an “inside look” at behavioral effects on care teams, said senior author Gerald Hickson, M.D., the Joseph C. Ross Professor of Medical Education and Administration at Vanderbilt.

“Unprofessional behavior modeled by the team reduces the effectiveness of the team,” he said. “If someone is disrespectful to you, how willing are you to share information or ask for advice or help from that individual?”

Changing behavior starts with sharing data related to patient and coworker reports. The researchers cite Vanderbilt’s “Project Bundle” as an instructive case study. The project included new reporting software, and an intervention that kept 71 percent of high-risk professionals free from subsequent reports at one year.

“Changing behavior is possible, even for clinicians with persistent patterns of unprofessional behavior.”

“Changing behavior is possible, even for clinicians with persistent patterns of unprofessional behavior,” Cooper said. Organizations that are interested in ensuring optimal patient outcomes can use reporting as a guide to address high-risk team members.

The researchers also note that a greater percentage of surgeons who had no reports of unprofessional behavior were women, suggesting that female surgeons may be less likely than their male counterparts to generate co-worker concerns.

About the Expert

William O. Cooper, M.D.

William O. Cooper, M.D., M.P.H., is professor of pediatrics and health policy at Vanderbilt University Medical Center. He is a pharmacoepidemiologist with a focus on the effects of psychotropic medications in children and adverse effects of prescription medication use during pregnancy. He has achieved international recognition for his work in using computerized databases to ask and answer important questions of drug safety.

Gerald B. Hickson, M.D.

Gerald B. Hickson, M.D. is senior vice president of quality, safety and risk prevention and Joseph C. Ross Chair of Medical Education and Administration at Vanderbilt University Medical Center. His work includes the development of PARS® and CORSsm programs that use unsolicited patient and coworker complaint data as the basis for tiered interventions for high-risk providers.