Verbal feedback from senior surgeons represents an essential part of surgical training. As an organizational psychologist who has spent time observing and measuring communication in the operating room (OR), I have observed a great deal of feedback from surgeons to surgical residents, students or more junior team members; most were constructive and expressed respectfully. However, in some cases, I observed feedback that seemed unsupportive and challenging to interpret, such as: “No, no, you should do this like this and not like this [showing how to handle an instrument], as I already told you twice. You are still working like an intern.”
Other researchers have described operating rooms as theaters where direct and harsh communication as well as subtle forms of tensions have been observed, that also target learners. Given that feedback conversations occur in settings with multiple layers of educator-learner relationships (e.g. a resident can be trained to perform a procedure by a fellow surgeon and towards the end of the operation show the student how to sew and close the tissues), the likelihood of feedback triggering interpersonal tension is very real. Educators take the provision and receiving of feedback seriously, because feedback is communication and communication is an important non-technical skill in surgery. Feedback that is not conveyed or perceived as useful can lead to a wide range of negative consequences. A meta-analysis found that, in one third of cases, feedback actually decreased performance instead of supporting performance. In a simulator, a senior surgeon who established a negative or psychologically unsafe environment dramatically reduced learners' speak up behaviors in critical clinical situations, and negatively impacted adherence to patient safety protocols.
Recent medical education literature suggests multiple models to communicate feedback. PEARLS or R2C2 are two examples, developed mainly to structure feedback after clinical situations or simulations. PEARLS - Partnership, Empathy, Apology, Respect, Legitimation, Support, was designed primarily for difficult feedback situations and aims at increasing the acceptance of the feedback by the learner while developing trust in the instructor-learner dyad. R2C2 – (build) Relationship, (explore) Reactions, (explore) Content, Coach, also emphasizes the importance of the relationship between instructor and learner and was developed based on the perspectives of both feedback givers and recipients.
Yet, few models are directly applicable to feedback in the OR. There are indeed unique challenges to giving and receiving feedback in complex clinical care settings which may preclude the provision and receipt of good feedback. Examples of such challenges include:
- Time pressure: In the OR, the time and cognitive resources necessary to thoughtfully prepare and structure feedback are reduced. Constructive feedback is given to prevent wrong techniques – and getting right to the point is necessary for patient care. Even if the patient is not at risk, time pressure is constant given that OR minutes are expensive, the list of patients to operate on is often long, and anesthesia-time of the patient must be as short as possible.
- Social context: One study found that surgery residents experienced shame mostly in the OR rather than in other work situations. The OR is a small space where many others can hear feedback – critical or otherwise. Thus, shame may be triggered not only by a negative self-evaluation but also by the presence of an audience (all the other team members). Alternatively, a solid culture of learning and psychological safety in the OR may prevent shame and fear of social judgement, as well as encourage learners to actively deal with critical feedback.
- Lack of longitudinal teaching relationships: The importance of the instructor-learner relationship has been long recognized as a key aspect of successful feedback. New residents, students and rotations are a reality and instructor-learner relationships are often of short duration. Every time educators are teamed with new learners, they must first gauge their technical skills and personality and adjust their feedbacks accordingly. On the learners’ side, not being yet familiar with the instructor may increase risks of misinterpretation of verbal and non-verbal communication, including feedback.
The above represent only some of the challenges academic surgeons face and demonstrate how work conditions create a fertile ground for tense feedback situations. In my ongoing research, I observe that misunderstandings happen, particularly in newly formed instructor-learner dyads and often reflect a fundamental attribution error. A better understanding of the instructor’s challenges by the learner and of the learner’s challenges by the instructor is a first step but obviously not sufficient to improve the provision and acceptance of feedback. Research has demonstrated promising results of interventions to increase medical education skills, including in surgery, suggesting that medical instructors who may not feel comfortable giving feedback can improve to become more efficient and valued feedback givers.
What are your best tips for offering feedback in the operating room? Join the conversation by commenting below!
Did you know that the Harvard Macy Institute Community Blog has had more than 190 posts? Previous blog posts have explored topics including The Curious State of Self: Efficacy, Awareness, Disclosure and Reflection, and #MedEdPearls on Frame Based Feedback and Feedback PLeaSe!
Sandra Keller, PhD is a work and organizational psychologist. Sandra currently holds a position as a postdoctoral research fellow at the Bern University Hospital in Switzerland. Sandra’s areas of professional interest include teamwork and tensions in the operating room. Sandra can be followed on LinkedIn or e-mail.