What a behind-the-scenes look at 200 surgeries revealed about gender dynamics in the OR

Conflict among surgical team members can have real-life consequences in the operating room (OR), and a study published last week in Proceedings of the National Academy of Sciences suggests that gender composition and hierarchies might play a role in team cooperation.

Study details

For the study, researchers at Emory University and Kaiser Permanente observed 200 surgeries at three different teaching hospitals using an ethogram—a logbook that researchers typically use to develop a specialized inventory of interactions when studying the evolution of a species. The researchers timestamped 6,348 spontaneous social interactions among clinical team members, including dancing, flirting, gossiping, insults, small talk, and teaching.

Key findings

Overall, the researchers found cooperation sequences occurred more frequently, at 59%, than conflict sequences, at 2.8%. The researchers defined conflict sequences as interactions that "ranged from constructive differences of opinion to discord and distraction that could jeopardize patient safety."

The researchers observed that gender composition and hierarchy were two key factors associated with a surgical team's level of cooperation.

The researchers found team cooperation was more common in instances in which the attending surgeon and the majority of the OR staff were opposite genders. Laura Jones, the study's lead author and a medical anthropologist at Emory University, said, "You see more rivalry between same-sex colleagues."

In addition, the researchers found the probability of a team cooperating fell when the attending surgeon and the majority of the team were male.

The researchers also observed associations between team cooperation and a surgical team's hierarchy, with conflict most frequently being directed downward.  For example, the researchers documented one case when a surgical fellow told a scrub nurse, "You, me, parking lot!" The nurse quit a few days after the interaction, STAT News reports.

According to the study, levels of surgical team cooperation varied by specialty—but the researchers added specialties' gender compositions should be taken into account when looking at those differences. For example, they found gynecological surgical teams—which were more likely to be mostly female—had the highest level of cooperation and the lowest level of conflict, while cardiothoracic surgical teams—which nearly always had a male attending—showed the highest level of conflict and the lowest level of cooperation.

Discussion

Jones said the researchers were surprised at how distinct some ORs were compared with others. "Just the culture [differences] between departments and between teams—you wouldn't recognize that it was even the same endeavor," she said.  

However, Jones noted that not all conflict in a surgical suite is bad, as team members need to feel comfortable raising potential problems. She said the "magic" relationship ratio is a 5:1 balance between positive and negative interactions.

To better achieve that balance, the researchers said the interpersonal components of cooperation and conflict should be addressed during the early stages of medical careers. Jones said medical schools can also become better at identifying "certain relationships and which ones tend to be more volatile in medicine," and surgical departments should support the use of more mixed-gender surgical teams.

Concerns over methodology

According to STAT News, some researchers have raised concerns over the study's design, particularly the researchers' use of an ethogram.

Jill Mateo, a behavioral ecologist at the University of Chicago and member of its Animal Behavior Research Group, said ethograms are designed to be descriptive, and should not be used to interpret observed interactions. She noted that the researchers in this ethogram recorded words such as "disintegrating," which she said makes it "interpretative, it's functional, it's making implications that we normally would not use in ethology."

Still, Mateo said she thinks the researchers' findings might remain consistent even if they used a more objective set of categories for their ethogram (Farber, STAT News, 7/2; Jones et al., Proceedings of the National Academy of Sciences, 7/2).

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