‘You, me, parking lot!’: Behind surgical curtain, researchers find hierarchies and gender dynamics driving conflict

On TV, operating rooms are a window into the perfect collaboration — surgeons, technicians, and nurses working seamlessly together for a common cause, the patient’s.

In reality, the focus of conversation is rarely on the patient. And the atmosphere is not always collegial.

A team of researchers at Emory University and Kaiser Permanente sat in on 200 surgeries at three different teaching hospitals, and logged each and every social exchange between clinical team members. What they discovered were complicated subcultures in which well-understood hierarchies and gender dynamics contributed to conflict — or helped alleviate it.

Laura Jones, a medical anthropologist and the lead author on the new study, published in the Proceedings of the National Academy of Sciences, said her team was surprised by how distinct some operating rooms felt compared with others, each scene playing out differently depending on which actors were present.

“Just the culture [differences] between departments and between teams — you wouldn’t recognize that it was even the same endeavor,” she told STAT.

Jones and her colleagues found that the gender composition of teams was strongly associated with its level of cooperation. If the attending surgeon was of the opposite gender as that of most other personnel in the OR, cooperation was more common.

If the attending surgeon’s gender matched that of the majority of teammates, higher rates of conflict ensued. “You see more rivalry between same-sex colleagues,” said Jones.

A surgical team is made up of hodgepodge of medical staff — surgeons, nurses, anesthesiologists, technicians, physician assistants, medical residents, and students. Each individual has a defined role and place in the hierarchy, with the attending surgeon serving as the leader of the group. Conflict, the researchers found, was most frequently initiated down the hierarchy — from a higher-up toward an individual several ranks below.

In one case documented in the study, a surgical fellow gave a scrub nurse the kind of order that might be more likely to come from a bully on the playground: “You, me, parking lot!” (The nurse quit his job just days later.)

The degrees of conflict and cooperation also varied by specialty. Gynecological surgical teams showed the highest level of cooperative communication and the lowest level of conflict. On the other hand, cardiothoracic surgical teams showed the highest percentage of conflict, and the lowest cooperation.

Specialty differences, the study showed, cannot be considered in isolation from the gender composition of those departments. For example, over 95 percent of attendings observed in cardiothoracic surgery were men. Looking at roles other than the attending, orthopedic and neurosurgery teams typically had mostly men the OR, while gynecology departments staffed mostly women. With more men in the room, the probability of cooperation dropped — especially when the attending surgeon was a man as well.

Jones and her team spent thousands of hours sitting under surgical theater lighting, keeping a constant record in a special logbook known as an ethogram.

They documented a wide array of social behaviors: small talk, gossip, professional exchanges, teaching, insults, flirtation, and even dance, as the surgeons often played music while they worked.

“Much of what stresses them out is petty little things and interpersonal relationships,” Jones said.

Jones emerged from this project with greater empathy for surgical teams — she said she appreciates how exhausting their work can be, and understands that they need to socialize to pass the time. But sometimes, she said, her peek behind the curtain revealed a difficult-to-accept reality. “You want to think that everything is streamlined, and that nobody is discussing what they’re discussing while working on your loved one.”

Some researchers expressed concern with the study design.

Ethograms, a kind of specialized inventory, are traditionally intended for observing nonhuman primate groups in the field of ethology, the study of an evolution of a species. The use of the tool in this study could be problematic, said Jill Mateo, a behavioral ecologist at the University of Chicago and member of its Animal Behavior Research Group.

Ethograms, she said, are supposed to be purely descriptive — documenting objective behaviors without any element of interpretation. In this case, however, Mateo said that the categories given in the ethogram — which include terms like “disintegrating,” referring to behaviors that threaten the function of the team — were not sufficiently objective. This ethogram, she said, is “interpretative, it’s functional, it’s making implications that we normally would not use in ethology.”

With the right ethogram, Mateo said, animal behavior methods can be applied to study humans. And despite her critiques of the study’s tools, she imagined that the findings would hold true with a more objective set of behavioral categories.

If that were the case, what lessons might be taken from the study?

In surgery, a high-stakes field that requires both technical and interpersonal skills, conflicts can be problematic for teamwork and can even threaten patient safety. But conflict isn’t all bad — as Jones said, team members need to feel comfortable calling one another out if there are problems. Jones and her co-authors refer to the theory of the “magic” ratio of cooperation to conflict, a 5:1 balance between positive and negative interactions. This ratio has been proposed in the context of successful marriages, and the researchers imply that, similarly, some degree of conflict is likely healthy in the OR.

Still, the study’s authors said, the interpersonal aspects of cooperation and conflict need to be addressed early in medical careers. They proposed greater interprofessional training for starters. And Jones said medical schools can do better to identify “certain relationships and which ones tend to be more volatile in medicine.”

Moreover, she said, surgical departments should encourage more mixed-gender teams.

A few more female neurosurgeons couldn’t hurt.