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

“Patients whose surgeons had four or more co-worker concerns had an almost 50% increased risk of having a surgical site infection [SSI],” he says. “That is an important increase when you think about all of the work we do to decrease the risk of our patients having infections.”

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 found. “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 researchers 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.

SSIs were significantly more likely among patients whose surgeons had more co-worker reports, with a rate of 5.3% in those with no reports, compared to 7.4% in surgeons with four or more reports of unprofessional behavior.

The researchers collected data on “many types of infections, including superficial SSIs, deep SSIs, catheter-associated bloodstream infections, and catheter-associated urinary tract infections,” Cooper said. “We measured across all of those different types of infections and found, in general, an increased risk for patients whose surgeons had more than zero co-worker reports.”

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,” the researchers reported. “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.”

Medical complications include pulmonary and renal problems, strokes, and pneumonia.

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

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

Clinicians working with volatile surgeons may be less likely to speak up if they see a break in protocol.

“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,” Cooper says.

While this behavior can have a chilling effect on workers speaking out, there also are workers who express concerns during a procedure, 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.”

The primary intervention for those with problems is to share the data with the surgeon, using a trained peer messenger, Cooper says.

“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 clinicians and work groups. For example, in hospitals that employ nurse-driven Foley catheter removal protocols, physicians on the floor may be angry to find their patients’ catheters removed, he says.

“We find that nurses are then reluctant to follow the protocols that we have worked so hard to put in place to protect our patients from infections,” Cooper says. “We know the longer you have a catheter in place, the greater the risk for infection.”

It is not all physicians, as continuing research by Cooper and colleagues suggests a similar pattern in advanced practice nurses.

“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,” he says. “As we look to extend this work to other types of clinicians in the non-surgical space, we do often find that the same behaviors are likely to affect important infection control practices.”

The authors of an accompanying editorial2 on the study said that surgeons may be at particular risk of these behavior problems.

“A hostile workplace is, unfortunately, not uncommon in academic surgery departments,” they noted. “Surgeons experiencing hostility in the academic surgical environment may have fewer professional advancement opportunities, less satisfying clinical practice, and failed mentorship, and may be at greater risk for burnout or other psychological effects.”

While these factors must be addressed, the study by Cooper and colleagues shows patient safety is at stake, the authors warned.

“As surgeons, we should have a zero-tolerance approach to unprofessional behavior in the workplace,” they concluded in the editorial.


  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.]
  2. Emerel LV, Kent T, Chu, D. Time for changes in the surgical community—promoting professionalism as #MeToo 2.0. JAMA Surg 2019; Jun 19. doi:10.1001/jamasurg.2019.1738. [Epub ahead of print.]