Broad commentary on JAMA Article

A recent study links professional conduct/workplace culture with quality and safety for patients, and has indicated that the patients of surgeons who have been reported by colleagues for unprofessional conduct are at a significantly increased risk of post-operative complications.

The study, published in JAMA Surgery medical journal in June 2019 compared the data of 13,653 patient outcomes with the number of complaints received about their surgeon over the three years prior to the surgery. The data was collected at two geographically diverse study sites that participated in the National Surgical Quality Improvement Program (NSQIP). A post-operative complication includes surgical and medical complications which occurred during the 30 day post-operative period.

Sixty-five per cent of all surgeons had no complaints lodged against them in the three years prior to surgery. The study found that post-operative complication rates were lowest among those surgeons who had received no complaints in the three years prior to the surgery and were highest among those who had received four or more complaints. The data indicated that the complication rate was 10.7 per cent for those surgeons with no complaints, 12.6 per cent for those with between one and three complaints and increased to 14.1 per cent among surgeons with four or more complaints.

The study estimated that a patient engaging a surgeon who has between one and three complaints made against them has an 18 per cent higher risk of post-operative complications when compared with surgeons with no complaints. This figure increases to 31 per cent when engaging a surgeon with four or more than complaints against them.

More than 70 per cent of the 202 surgeons considered by the study were male. The rate of complaints about female surgeons was lower, suggesting that women were ‘less likely to generate co-worker concerns than men’.

Patients of surgeons with complaints lodged against them were more likely to be classified as less fit under the American Society of Anesthesiologists (ASA) system. The patients of those doctors with no complaints had a higher than average chance of having an ASA classification of 1 or 2, meaning no disturbance or mild disturbance respectively. Conversely, patients of these surgeons were less likely than average to be classified as a 3 or 4 on this scale, meaning severe disturbance and life threatening disturbance respectively. Surgeons with one or more complaints have greater than average numbers of patients in this more severe range.

Patients of surgeons who had more than four complaints made against them were significantly less likely to have clean wounds and higher than average incidences of infected or contaminated wounds. They also took longer to conduct surgery. Whilst the study shows distinct differences in some areas, there is no significant differences in serious effects such as death, reoperation or readmission within the 30 day post-operative period.

Recommendation

The main recommendation which comes from this study is that organisations interested in ensuring optimal patient outcomes should address the behaviour of surgeons in their interaction with colleagues. Doing so may reduce the risk of adverse outcomes for their patients.

The study focusses on the effect of complaints on relationships between medical professionals and their potential in undermining safety. The study found that the negative effect of colleague complaints on workplace culture seems to have an effect on the quality of surgery and negatively affect patient outcomes. It held that ‘[s]urgeons who model unprofessional behaviours may undermine a culture of safety, threaten teamwork and thereby increase the risk for medical errors and surgical complications’.

Variables

Although the research highlights the negative effect of complaints upon professional culture, the study recognises that other variables may affect the number of complaints a surgeon has made against them. Factors which affect the number of complaints made may include the willingness of colleagues to make complaints. The subjective nature of reporting dictates that some people may be more inclined to report behaviour and may do so for various reasons. The researchers attempted to mitigate the effect of this cultural factor in their analysis. Similarly, the methodology of the study accounted for the effect of surgeon experience on post-operative complications.

While the study focusses on the effect of complaints on workplace culture and the relationships between colleagues, there may also be other factors which lead to post-operative complications. The study grouped the behaviour which was the subject of complaint into four categories; concerns about poor or unsafe care in the operating theatre, clear and respectful communication with colleagues, integrity and responsibility. Some complaints may have a more direct impact upon patient outcomes, rather than the indirect way the study addresses. This may be particularly true of complaints regarding poor or unsafe care.

This study builds upon other work in the area and aims to develop more research into the improvement of patient outcomes. The study found that there may be value in further research that considers whether interventions on surgeons who have exhibited patterns of unprofessional behaviour associated with surgical outcomes leads to improved interactions with patients, families and co-workers.