February 1, 2020
Editor’s note: The Communications Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) offers an annual essay contest. The theme of the 2019 essay contest was Cut It Out: Changing the Status Quo. The winning essay follows.
Recently, I heard a scrub technician compliment a staff surgeon this way: “I’ve never seen him throw an instrument.” There is no reason to laud reasonable behavior, except in the context of a culture of abuse.
Surgery as a field remains troubled by a paternalistic and frequently angry social character. Euphemistically called “disruptive behavior,” abusive conduct has been addressed as a patient safety issue by The Joint Commission, with an alert in 2008 and a mandate for policy in 2009.1 Estimates of the prevalence of disruptive behavior are high; 77 percent of the respondents in one study said they had witnessed physicians engaging in disruptive behavior.2
A sign posted in 2018 outside of the operating rooms at a Sacramento-area hospital. There is no corresponding female doctor locker room, though some female doctors use the doctor locker massage chairs after hours.
These numbers don’t surprise me. I decided to pursue a career in surgery in spite of the culture as I had experienced it—the uncomfortable comments, male superiors who stood too close, and demeaning treatment from residents and fellows. Early in my residency, to get some perspective on the culture I am enmeshed in, I read Forgive and Remember: Managing Medical Failure by Charles L. Bosk, PhD.3 The cultural characteristics of surgery that Bosk described in this sociological study—male, cold, rational, typified by abuse and harassment—rang true to my observations almost 40 years later.
In 1979, perhaps this reality was kept quiet. In the early 21st century, it is openly discussed and studied. Nonetheless, disruptive physicians still are often given a pass, frequently on to other institutions. Culture is slow to change.
The culture of surgery is ripe for disruption of this disruptive behavior, and indeed this shake-up is happening. We must insist on respectful conduct as a minimum. While administrative actions are ongoing, needed, and welcome, the ultimate focus must be on change in conduct on the personal, day-to-day level, reaching all levels of the hospital hierarchy.
One way we can support this shift is by increasing diversity in surgery, as many surgeons and leaders are working to do. We need gender parity in surgery as a bulwark against the long-accepted behavioral norms we’ve inherited from our (overwhelmingly) male antecedents.
Women accounted for 34 percent of physicians in the U.S. in 2015, and just 19 percent of general surgeons.4 Patients need women in surgery. A Canadian study of 1.2 million patients found decreased odds of death among patients treated by female surgeons compared with patient mortality rates among male surgeons, controlling for differences in patient factors and surgeon factors.5 We must make our profession inclusive and positive in order to provide the best care for our patients while being well, whole, people.