Patients are at greater risk of complications and adverse outcomes if surgeons break team protocols or treat colleagues poorly, reports William O. Cooper, MD, MPH, of the Center for Patient and Professional Advocacy at Vanderbilt University School of Medicine in Nashville, TN.

“You can see in a complex surgical operation how that would potentially impact things,” he says. For, example, when a patient is not doing well, the surgeon may yell at an anesthetist.

“The next time they are paired together, that anesthetist may be distracted, waiting for the surgeon to blow — or be hesitant to speak up if the patient’s blood pressure starts to drop or the patient is not doing well,” he tells Hospital Employee Health.

Cooper and colleagues hypothesized that patients of surgeons with a higher number of co-worker reports about unprofessional behavior could experience a higher rate of postoperative complications than patients whose surgeons have no such reports.

“Among 13,653 patients in this cohort study undergoing surgery performed by 202 surgeons, patients whose surgeons had a higher number of co-worker reports had a significantly increased risk of surgical and medical complications,” the authors wrote. “Surgeons who model unprofessional behaviors may help to undermine a culture of safety, threaten teamwork, and thereby increase risk for medical errors and surgical complications.”1

The study assessed data from two academic medical centers in the National Surgical Quality Improvement Program. Both hospitals acted on reports from co-workers describing unprofessional behavior by surgeons.

The researchers went back three years preceding an operation in assessing reports of unprofessional behavior by the surgeon. The main outcomes assessed were postoperative surgical or medical complications within 30 days of the operation.

Among 13,653 patients who underwent operations performed by 202 surgeons, 1,583 experienced complications.

“Patients whose surgeons had more co-worker reports were significantly more likely to experience any complication,” they found. “The adjusted complication rate was 14.3% higher for patients whose surgeons had one to three reports, and 11.9% higher for patients whose surgeons had four or more reports compared with patients whose surgeons had no co-worker reports.”

The researchers examined four types of behaviors that generated reports by co-workers. One was failing to follow accepted care protocols, such as handling a central line without gloves, Cooper says. Others included unclear or confusing communications from the surgeon to colleagues.

“There were some that were just rude and disrespectful,” he says. “Others were just failing to follow through on professional responsibilities like signing verbal orders, or other things that are an important part of team function.”

While this behavior can have a chilling effect on workers speaking out, some workers also express concerns during procedures, he explains.

“In our work, we find that many times a nurse or another worker does speak up and reminds the surgeon, but he goes ahead and does it anyway,” he says. “The clear majority of surgeons, like all physicians, perform in perfectly respectful ways and never have any problem at all. It is a very small proportion that account for a disproportionate share of these kind of behaviors.”

Put simply, the patients of these bad actors are at higher risk for surgical site infections and other adverse events.

“We also looked at things like strokes, pneumonia, and urinary tract infections,” Cooper says. “We found that danger increased in most surgical and medical complications.”

The primary intervention is sharing the data with the surgeon, using a trained peer messenger.

“We find that 80% of the time that a surgeon or another physician is an outlier, they will self-correct and reduce the number of unprofessional behaviors they have,” he says. “For the small number of individuals who don’t respond to the peer intervention, we recommend that hospitals do a physical and mental health evaluation to see whether there could be burnout, mental illness, substance abuse, or other problems.”

Ongoing research indicates that this general pattern could manifest in other healthcare teams and work groups.

“We have studied this in advanced practice nurses and see a similar type of distribution,” Cooper says. “We are piloting some work looking at staff nurses, and we are seeing there is a non-random distribution that a small number of nurses account for a disproportionate share of unprofessional behaviors. We are proposing and planning to implement similar interventions.”


  1. Cooper WO, Spain DA, Guillamondegui O, et al. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surg 2019 Jun 19. doi:10.1001/jamasurg.2019.1738. [Epub ahead of print.]