Teamwork in the Operating Room: A Survey on Anesthesiologist-Surgeon Interaction in a German University Hospital Setting

Abstract

Objective:

Effective communication between surgeons and anesthesiologists in the operating room (OR) is essential for patient safety, but communication deficits remain a leading cause of medical errors.

Methods:

An anonymous, interdisciplinary online survey was conducted to assess communication in the OR at a single university hospital. The target population included all surgeons and anesthesiologists, regardless of career level (n=837). The questionnaire consisted of 28 items covering 5 thematic domains. It was distributed via email and available from January to March 2024. No incentives were provided. Data were analyzed descriptively and comparatively using the χ² test.

Results:

A total of 183 participants (55% anesthesiologists, 45% surgeons) were eligible. A desire for more or substantially more communication in the OR was expressed by 67% of respondents. Preventable incidences caused by communication deficits were reported by 65% of participants, with anesthesiologists being significantly more likely to report both. Gender-based discrimination in the OR was experienced by 36% of respondents with both anesthesiologists and female physicians being significantly more often affected.

Conclusions:

This interdisciplinary survey revealed communication gaps, preventable incidents linked to poor communication, and perceived gender-based discrimination between anesthesiologists and surgeons in the OR. Sixty-five percent of respondents link these deficits to preventable patient safety incidents. These results can serve as an exemplary case for similar hospital organizations or acute care settings and help promote gender equality. These findings underscore the need for respectful dialogue and strong interdisciplinary collaboration in operating rooms.

The specialties of surgery and anesthesiology inherently maintain a close relationship, which requires an effective interdisciplinary communication. However, communication deficits and poor teamwork, especially in the operating room (OR), have been identified as leading causes for medical errors, accounting for up to 70% of adverse events.^1–5 Communication in general is influenced by factors such as gender dynamics and role distribution. Communication within the OR, especially during surgery, is even more complex. Next to the abovementioned general hurdles of gender and hierarchy conflicts, OR communication is significantly impeded by conflicting interests, interruptions, and interpersonal interactions, such as casual conversation, personal tensions, teaching, and professional exchange.⁶

Within the last 2 decades the influence and importance of human factors and nontechnical skills on patient safety has gained increasing acceptance in the field of anesthesiology. A major human factor is the interpersonal interaction.⁷ Interaction deficits lead to intraoperative interruptions, decreased efficiency, miscommunications, and consequently reduced quality of patient care.^2,3 Still, up-to-date, detailed data on specific communication needs and deficiencies between surgeons and anesthesiologists in the OR is spare.

The aim of the present survey was to examine discipline- and gender-specific communication needs among surgeons and anesthesiologists in the OR in a large university hospital setting. These results can serve as an exemplary case for similar settings to raise awareness and improve interdisciplinary communication.

METHODS

An anonymous online questionnaire (LimeSurvey GmbH, Hamburg, Germany) was designed using an interdisciplinary approach. The target population consisted of all surgeons and anesthesiologist (n=837) at a level I University hospital (LMU University Hospital Munich). The study was approved by the local institutional review board. Each participant was educated about the study and had to provide informed consent before the survey.

The survey was designed by the authors and checked for biased questions, wording, and scaling by an independent, external expert. The usability and technical functionality of the electronic questionnaire had been tested before fielding the questionnaire. The survey was accessible for each participant who had received the link. The link was distributed via personal e-mail to each physician associated to one of the 13 surgical departments or to the department of anesthesiology. Study participation was voluntary without any incentives or remuneration. The data were collected between January and March 2024.

The LimeSurvey comprised of 5 pages with a total of 28 questions. These questions were grouped into baseline characteristics, appreciation, communication in the OR, perception of the surgeon/anesthesiologist, and gender-related questions. The questions were scaled using an ordinal or binary scale as appropriate and referred to the current status quo in the OR. Basic characteristics included gender, specialty, and level of training (1st-3rd and 4th-6th years of residency, consultant, senior consultant, and leading position). The survey was conducted in German language. The English-translated questionnaire is provided in the supplementary material, Supplemental Digital Content 1, http://links.lww.com/JPS/A780. Answered questions of not terminated questionnaires have been analyzed as well. No cookies were used to assign a unique user to each computer, as computers are used by several physicians within our hospital.

No patient data was collected. Data analysis was conducted both descriptively and comparably, using the χ² test (GraphPad Prism 10.0.0, Boston, MA). The design and reporting of this e-survey adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines.⁸

RESULTS

Out of 837 physicians contacted, 199 participants (24%) started the survey (agreed to informed consent). Out of those, 189 (95%) answered at least one question and 127 (64%) participants answered all questions. Included in the further analysis were all 183 (92%) participants who had indicated their profession. One hundred and one participants were anesthesiologists, 82 surgeons. Table 1 provides an overview on the demographics, separately for anesthesiologists and surgeons.

TABLE 1.

Demographic Data of Respondents (Surgeons and Anesthesiologists)

	Anes. (%)	Surg. (%)	Sig.
Sex
Female	50 (49.5)	32 (39)	ns (P=0.35)
Male	50 (49.5)	48 (59)
Nonbinary	0 (0)	0 (0)
Missing answer	1 (1)	2 (2)
Training level
Resident < 4th year	21 (21)	19 (23)	ns (P=0.12)
Resident ≥4th year	32 (32)	18 (22)
Consultant	22 (22)	12 (15)
Senior consultant	26 (26)	33 (40)
Subspeciality
Visceral Surgery: 20%, Trauma Surgery/Orthopedics: 17%, Neurosurgery: 15%, Gynecology: 12%, Urology: 10%, Ophthalmology: 6%, Cardiac Surgery: 6%, Oral/Maxillofacial Surgery: 5%, Pediatric Surgery: 4%, Vascular Surgery: 2%, ENT (Ear, Nose, and Throat): 1%, Plastic Surgery: 1%, Thoracic Surgery: 1%

Anes. indicates anesthesiologists; Sig., significance; Surg., surgeons.

Communication was assessed for both quantity and quality. Regarding quantity, 67% of respondents (112/167, missing: 16) expressed a desire for more or substantially more communication with the other specialty (surgeon or anesthesiologist) (Fig. 1). The desire for more or substantially more communication varied significantly between the specialties (92% anesthesiologists (84/91, missing: 10) versus 37% surgeons (28/76, missing: 6); P<0.001) and the different training levels (P=0.002). Notably, residents from both disciplines expressed a significantly greater need for communication than senior positions. Gender had no significant impact.

FIGURE 1.

Desired amount of communication by anesthesiologists (Anesth.) and surgeons (Surg.) in the operating room (OR) compared with the status quo (percentage per discipline, n=168).

In terms of communication quality, 48% of anesthesiologists (43/90, missing: 11) versus 3% of surgeons (2/76, missing: 6; P<0.001) rarely felt that communication was open and honest. Gender and hierarchy did not significantly affect this perception. Thirty-four percent of respondents (60/176, missing: 7) reported that they rarely or never felt appreciated—in the sense of feeling valued—by the other specialty with female gender (P=0.004) and anesthesiologists (P<0.001) reporting this significantly more often. The experience of positive feedback in the OR within the past 2 weeks significantly influenced the degree of appreciation (P<0.001).

Patient safety was directly affected by communication in the OR. Sixty-five percent of respondents (106/163, missing: 20) indicated that they had experienced incidents that could have been avoided with better communication between the 2 disciplines [76% of anesthesiologists (70/92, missing: 9) and 51% of surgeons (36/71, missing: 11, P=0.001)] (Fig. 2). Gender or level of training did not significantly impact this.

FIGURE 2.

Percentage of anesthesiologists (Anesth.) and surgeons (Surg.) that have experienced incidents in the operating room (OR) that could have been avoided through better communication between both disciplines (percentage per discipline, n=164).

Regarding misunderstandings during communication, 25% of respondents (42/169, missing: 14) rarely asked for clarification. No significant differences were found between specialties, gender, or training levels. Regarding criticism—in the sense of negative feedback—19% of all respondents (32/166) stated that they always, 48% (80/166) often, 31% (51/166) rarely, and 2% (3/166) never communicate when something concerned them during surgery (missing: 17). Again, no significant differences were found between gender, specialty, and training level.

Discrimination based on gender in the OR was reported by 36% of respondents (58/160, missing: 23) (Fig. 3). Both, female gender (P<0.001) and specialty of anesthesiology (P=0.005) affirmed this significantly more often. In fact, 76% of female anesthesiologists (38/50, missing: 6) and 44% of female surgeons (14/32, missing: 5) reported experiencing gender-based discrimination in the OR. Hierarchy did not significantly affect this.

FIGURE 3.

Percentage of anesthesiologists (Anesth.) and surgeons (Surg.) of each gender who report current discrimination in the operating room (OR) (percentage per gender, n=158).

In addition to general discrimination, 35% of respondents (55/159, missing: 24) reported that they have received sexist comments from the other specialty in the OR. Female participants [62% (44/71, missing: 11) versus 13% male participants (11/86, missing: 12), P<0.001] and anesthesiologists [45% (40/88, missing: 13) versus 22% surgeons (16/73, missing: 25), P=0.002] reported this significantly more often. The level of training had no significant impact.

DISCUSSION

This survey, conducted among 183 surgeons and anesthesiologists at one of the largest German University hospitals, provides valuable insight into interdisciplinary perception of communication between surgeon and anesthesiologist and its potential impact on patient safety in the OR. To the best of our knowledge, this is the first joint survey among surgeons and anesthesiologists to examine discipline- and gender-specific communication differences.

The study found significant differences in the perception of communication between surgeons and anesthesiologists. Anesthesiologists more frequently expressed a desire for open and in-depth communication compared with surgeons. Effective communication between surgeons and anesthesiologists plays a critical role in ensuring patient safety in the OR. Communication errors have been shown to be a significant cause of critical incidents. Still, there is limited data addressing the different needs of communication regarding these 2 specialties.^1,9 In this exploratory survey, 65% of the respondents indicated that better communication could have prevented critical incidents in the OR. Approximately one quarter of respondents of both disciplines expressed reluctance to seek clarification in situations of uncertainty, while one-third were hesitant to voice criticism. Reasons for these hesitations included perceptions that criticism would be unproductive, intimidation due to hierarchical structures, fear of conflict, and time constraints.

Contrary to the common expectation that medical doctors should act without error, research shows that human mistakes are an inherent part of normal brain function. These “errors” represent natural cognitive processes that result in negative feedback loops in the brain, which have played a key role in human evolution and are essential for behavioral adaptation. Therefore, training in nontechnical skills during medical education and residency is crucial for ensuring patient safety. Nontechnical skills include cognitive and interpersonal competencies, which complement technical skills and address human factor issues in patient care. Important frameworks describing these competencies include “Anesthesia Crisis Resource Management” (ACRM) and the behavioral marker system “Anesthesia Non-Technical Skills” (ANTS).⁷

Necessary nontechnical skills in the OR can be categorized, according to the ANTS framework, into 4 domains: situational awareness, decision-making, task management, and teamwork.¹⁰ Effective communication plays a central role in collaboration between surgeons and anesthesiologists and serves as an essential tool enabling all other skills. It can be strengthened through respectful and appreciative communication. Table 2 shows the different elements of the aforementioned nontechnical skills. When focusing on teamwork in the OR, it should encompass coordinated activities among team members, clear information exchange, defined leadership roles with effective leadership behaviors, assessment of capabilities, and mutual team support (ANTS).¹⁰

TABLE 2.

Essential Nontechnical Skills in the OR Adapted From “Rating Non-Technical Skills: Developing a Behavioral Marker System for Use in Anesthesia,” Fletcher et al. 2004¹⁰

Category	Items
Task management	Preparing and organizing work effectively
	Setting priorities according to clinical needs
	Establishing and upholding performance standards
	Identifying, allocating, and using resources efficiently
Teamwork	Coordinating actions with colleagues
	Sharing relevant information clearly and in a timely manner
	Demonstrating appropriate authority and confidence
	Recognizing team members’ abilities and providing mutual support
Situation awareness	Collecting and interpreting key information
	Understanding the current clinical context
	Anticipating future events or complications
Decision-making	Generating and considering possible options
	Evaluating risks and choosing the best course of action
	Reviewing and adjusting decisions as the situation evolves

The Guidelines on human factors in critical situations 2023 recommend strongly implementing briefing and debriefing sessions as well as closed looped communication in order to help to improve quality of care and patient safety.¹¹ The growing use of simulation-based incident training reflects the increasing recognition of the importance of human factors and nontechnical skills in ensuring patient safety. Further improvement potential lies in establishing a standardized definition of the components of Crisis Resource Management (CRM) training in health care, as well as setting clear guidelines regarding the duration of such training and the qualifications of the trainers. The development of these skills should be integrated into residency programs through simulation-based training, educational formats emphasizing the significance of human factors, and supervision that models these behaviors by example.¹²

In contrast to these requirements, our current study showed that anesthesiologists significantly more often indicated too little communication, as well as a lack of honest and appreciative communication. Whether this is due to surgeons practicing these qualities less frequently, or whether anesthesiologists have a higher need of these qualities in comparison to their surgical colleagues due to specialty-specific conditions (e.g. the influence of surgical actions on hemodynamic consequences) cannot be clarified due to the subjective nature of this study. Previous studies were able to proof an association between intraoperative stress levels and nontechnical skills, such as teamwork and communication, in surgical teams. Interestingly, improved intraoperative teamwork was associated with increased stress levels among surgical team members.^13,14 It remains unclear whether enhanced teamwork served as a compensatory mechanism in response to increased intraoperative demands, or whether the increased levels of leadership and communication themselves contributed to additional stress for the surgeons.¹⁵

Tailoring communication primarily to one’s own requirements may fail to meet the needs of another colleague in the OR. But the awareness of the communicational needs of your counterpart can improve the interaction. This applies not only to specialty-specific needs but also to training-specific needs, with less experienced colleagues possibly requiring more information or verbal confirmation. Communication in the OR is further limited by the overall noise level, not directly addressing communication partners, and the absence of facial expressions or gestures. All of these factors can lead to differing interpretation of the situation and, consequently, divergent courses of action.

Furthermore, disruptive behaviors, such as mobbing or discrimination, contribute to poor team communication and increased the risk for medical error.^6,16 Physicians working in high-pressure environments like the OR, where stress, psychological strain, and fatigue are common, are at higher risk for experiencing such behaviors.^1,17 Gender-specific discrimination was reported by over a third of respondents, with anesthesiologists and female physicians being disproportionately affected. Sexist remarks constituted one form of discriminatory behavior, as confirmed by one-third of the respondents, in particular, women and anesthesiologists. A qualitative multicenter study performed among health care professionals in Canada identified gender as the third leading barrier to effective teamwork. Gender had an influence on the perception of competence and communication practices.¹⁸ In our institution, designated contact points for individuals seeking support include the Equal Opportunities Officers and the unit for Occupational Health and Conflict Management, which provide confidential counseling for employees experiencing discrimination or sexual harassment. Furthermore, an anonymous Critical Incident Reporting System (CIRS) is available to report potential risks affecting patients or staff members. Reports submitted via CIRS are handled confidentially by trained personnel, who systematically evaluate the incidents and, where appropriate, implement preventive and quality improvement measures. Considering the results of this study, an evaluation should be undertaken to determine to what extent preventive measures, such as mandatory training on diversity, equity, and inclusion (DEI) and gender bias training, could be implemented within our institution to prevent discrimination.

Stereotypical perceptions of leadership, often aligned with traditionally male, authoritative behavior, continue to shape expectations in the OR, particularly among surgeons. Inclusive leadership styles, more commonly associated with female traits, challenge these established norms but are less widely accepted. Examining unconscious attitudes towards gender stereotypes in the OR may improve teamwork dynamics and lead to a safer patient environment.¹⁹

Several limitations must be discussed. First, a possible sampling bias and self-selection bias, as participation was voluntary. In the overall population, 35.6% were anesthesiologists and 64.4% were surgeons, whereas in the respondent sample, 55.2% were anesthesiologists and 44.8% were surgeons. This might very well be explained by a varying level of awareness with the survey topic among surgeons. Thus, the professional distribution does not fully match the total cohort. However, within the surgical and anesthesiology group, the distributions of sex and training level were highly similar across the composition, suggesting that the respondents are broadly representative of the overall target population. Thus, while we acknowledge the limited response rate, we consider the risk of substantial sampling bias to be low. A further limitation was the discipline-specific gender disparities, with a higher proportion of surveyed women in the field of anesthesiology. Consequently, it is not possible to conclude whether discriminatory differences between departments would persist if gender distribution were equal. However, these discipline-specific gender disparities reflect the real-world condition within our hospital. Further limitations include the single-center design and the retrospective assessments of the participants carry the risk of hindsight bias.

The current study highlights the varying needs and the existing discrimination in the OR. Mutual understanding and training can ultimately improve the quality of care.²⁰ Implementing communication strategies, such as relational coordination, where both parties work towards shared goals through mutual respect and knowledge, could reduce critical events and increase staff satisfaction.²¹ The concept of “Crisis Resource Management” should also be trained in interdisciplinary interactions and the training of nontechnical skills should be implemented in operating rooms. Ways of teaching and implementing Crisis Resource Management include simulation-based training, pedagogical concepts such as the teamwork training system TeamSTEPPS 2.0 as well as for example, workshops often conducted by psychologists or pilots. For these trainings to be effective, an interactive format is crucial, rather than traditional lecture-based teaching, and should be accompanied by a long-term, strategically planned organizational change process.¹² Closed-loop communication (confirming messages), active listening (being responsible to understand the message and asking for clarification until this goal is reached) as well as speaking up (suggestions are acknowledged by leadership) further improve communication.¹²

CONCLUSION

This interdisciplinary survey revealed communication gaps and perceived gender-based discrimination between anesthesiologists and surgeons. Sixty-seven percent of respondents had a desire for improved communication. Especially anesthesiologists sought more frequent, honest, and appreciative exchanges. Sixty-five percent of participants reported preventable incidents linked to poor communication. These findings highlight the impact of communication on patient safety and call for reflection and stronger interdisciplinary collaboration in the OR.

Supplementary Material

pts-22-0400-s001.docx ^{(20.6KB, docx)}