Excising the “surgeon ego” to accelerate progress in the culture of surgery

What is the problem?

Overconfidence has long been noted as a potential problem among doctors,9 but the practice of surgery has a particular reputation for arrogant, ego oriented behaviours. In a study of personality traits among UK healthcare professionals, surgeons were found to have significantly higher levels of narcissism (a personality characteristic that manifests in egotist, arrogant, or dominant attitudes10) than their non-surgeon colleagues.11 Other research has found greater numbers of disruptive behaviours and patient complaints among surgeons than non-surgeons, which could be the result of more arrogant attitudes (alongside the high stakes, high stress environment of surgery).1213141516

Arrogant behaviour among surgeons is certainly not universal and very likely varies across specialties or departments, though existing data at the specialty level are insufficient to draw more substantial conclusions.11 But just a few “bad apples” can disrupt patient care and perpetuate the reputation of surgical culture as ego oriented.3 Medical students often perceive surgeons as overly self confident to the point of arrogance, and think that they would need to fit this stereotype to be a successful surgeon.121317 This perception is shared by other health professionals. In a Swiss study, ratings provided by nurses showed a shared perception of surgeons as less socially oriented and more aggressive than internists.18 Notably, these perceptions were supported by self reported ratings from doctors in the study, with surgeons rating themselves as more aggressive than internists.18

This widespread perception raises a concern about self selection, where people comfortable with this behaviour are more likely to enter the specialty and, more importantly, where the profession loses promising candidates who are averse to these behaviours. A study of US medical students found that those who chose technique oriented specialties (including surgery) tended to be more dominant and less warm than those who entered person oriented specialties.19 Compounding this selection effect, surgical training may perpetuate ego oriented behaviour “down the chain” as trainees model the behaviour of more senior surgeons, and unintentionally encourage trainees to carry forward disruptive behaviours in their future practice.312 These dual pressures of selection and socialisation are worrisome because they may push well intended individuals from reasonably confident to problematically arrogant through the course of surgical training. In a study at a large US academic medical centre, for example, surgical residents and faculty scored significantly lower on the personality characteristic of agreeableness (the tendency to exhibit altruism, trust, and modesty) than did faculty and residents in medicine and family medicine. Moreover, the surgical faculty also scored significantly lower on agreeableness than surgical residents,20 a troubling trend across these different career points.

Conceptualising the “surgeon ego”

One obstacle to tackling the effects of surgeon ego is the fragmentation of research in this area, with studies focusing on different manifestations—such as narcissism, arrogance, dominance, and disruptive behaviour. Fig 1 shows how these disparate findings relate to each other, offering an integrated understanding of what is meant by the surgeon ego.

Fig 1

Organising framework for causes and consequences of surgeon ego

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Specifically, many of the surgeon attitudes and behaviours described in research are manifestations of an underlying characteristic of narcissism, considered a subclinical personality characteristic possessed by most people to varying degrees.10 Narcissism, evident to others as “arrogant, self promoting, aggressive” attitudes,10 is a driver of disruptive behaviour in the perioperative environment (thought it can also result from situational stressors or other cultural conditions).12 In turn, these attitudes and disruptive behaviours can have a detrimental effect on outcomes relevant to patients and providers.

What are the consequences?

Healthy self confidence has an important role in medicine, especially surgery.21 The ability to take decisive action in the face of complex, time sensitive, and high stakes procedures requires a confident disposition and belief in one’s own abilities to step up and lead. But in the modern era of multidisciplinary care, where the “captain of the ship” is less clear,22 this confidence should not give way to a more disruptive ego.

Notwithstanding the preceding examples, we found relatively little research directly examining the performance consequences of surgical ego. Yet drawing on established literature in the organisational sciences, we can infer the consequences of ego driven behaviour among surgeons. Higher levels of arrogance in the workplace, for example, are associated with worse job performance,23 and meta-analytic evidence shows a strong association between narcissism and counterproductive behaviours in organisations and between narcissism and worse job performance for those in positions of authority.1024

Some surgical research has examined the outcomes of surgeon ego indirectly. Cooper et al found that patient complaints about intimidating or disrespectful behaviour predicted complication and readmission rates for that surgeon.8 At the same time, substantial research has shown how disruptive behaviours can divert attention from patient care, while also increasing medical errors and affecting the wellbeing, turnover, and collaboration of others in the perioperative environment.5131425 And conversely, surgeons’ interpersonal effectiveness and non-technical skills (such as teamwork, communication, and cooperation) are increasingly being identified as drivers of technical performance26 and the differential ability of surgical units to rescue patients after major postoperative complications.272829

One particular consequence of the surgeon ego is that it may deter women from pursuing surgical careers.30 Alongside perceptions of arrogance and intimidation, medical students report perceiving the practice of surgery as “masculine” and feeling pressured to conform to that norm (or feeling that they must be highly exceptional to succeed without conforming).17 At the same time, much attention has been paid to recent evidence of better outcomes for the patients of female surgeons than those of male surgeons.303132 Though we cannot say definitively that surgeon ego is linked to sex, more than half of doctors and nurses who responded to a survey on disruptive behaviour reported that male doctors engage in more disruptive behaviour, whereas only 2% reported that female doctors engage in more disruptive behaviour, and 41% reported no difference.25 Moreover, meta-analytic findings in the general population show that men consistently score higher on measures of grandiose narcissism than do women.33

What are the paths forward?

Considering these negative consequences for teamwork, wellbeing, and patient care, the surgical community must recognise and tackle practices and norms that might unintentionally encourage or condone ego oriented behaviour. Effective change will require a multidisciplinary effort from surgeons, anaesthesiologists, nurses, and the many other professionals vital to perioperative care. Bramhall was not alone in the operating room when he cauterised his initials into patients’ livers, yet no one stopped him. It wasn’t until years later that he was held accountable. A key first step is simply acknowledging that this behaviour—both in its extreme and less severe manifestations—disrupts interprofessional teamwork, decreases situational awareness, and inhibits communication in ways that ultimately affect patients.

Creating lasting change, however, necessitates systematic efforts to understand and deal with these behaviours (with grounded interventions and reliable assessment of key outcomes) and will require altering the fundamental norms and practices that may unwittingly encourage these behaviours. We need more research to directly assess the effects of surgeons’ differing interpersonal behaviours on care outcomes and patient perceptions. Responsibility for developing this evidence based, interprofessional approach lies with all levels of surgical practice, including not only professional associations and regulatory bodies but also the leadership of hospitals and departments and the peer community of surgeons.

Professional associations can set the agenda for dealing with ego concerns by setting guidelines and developing training materials regarding these disruptive attitudes and behaviours—similar to the non-technical skills training modules developed by the Royal College of Surgeons of Edinburgh.34 Surgeons look to these associations and regulatory bodies for not only awareness of important issues, but also concrete recommendations for action. Some surgical governing bodies have stepped up efforts to combat negative aspects of surgical culture, including the Royal Australasian College of Surgeons’ 2016 Let’s Operate with Respect campaign, which was focused on ending bullying, discrimination, and sexual harassment in surgery.35 These surgery specific efforts can bolster existing, broader endeavours, such as the American Medical Association’s development of health systems science as the third pillar of medical education (joining basic and clinical sciences).36 This curriculum provides a framework for understanding aspects of healthcare delivery not traditionally taught in medical schools, such as teamwork and leadership.

At the same time, the leadership of surgical departments, hospitals, and schools of medicine should focus on attitude and disruptive behaviour when recruiting and promoting people to positions of authority. Many healthcare systems and their leaders have made efforts in recent years to create the necessary infrastructure and support to curb ego driven behaviour across the medical profession (not only in surgery). The Center for Professionalism and Peer Support at Brigham and Women’s Hospital has pioneered interventions for reducing disruptive behaviours and improving the quality of physician peer interaction.37 Likewise, the University of Michigan Department of Surgery’s “Michigan Promise” is a longitudinal investment to create an inclusive and welcoming environment for current and future surgeons.38 Yet these efforts are often not fully integrated into the systems used for training, selecting, or promoting surgeons, representing a key opportunity for matching intention with action. Departments could develop in-depth, interpersonal simulations for assessing and training surgeons as they engage in the complex interprofessional dynamics of an operating room. Simulation methods have been used to evaluate these types of interpersonal, non-technical skills when hiring department chairs,39 revealing key insights into leadership skills and attitudes. Interpersonal simulations can also be beneficial if incorporated into the training of surgical residents,40 helping to break the cycle of selection and socialisation described earlier.

These organisational efforts would undoubtedly advance the field’s understanding and ability to tackle the causes and consequences of surgeon ego, but they may be isolated to specific institutions or regions, emphasising the need for the entire surgical community to recognise and deal with these behaviours among their peers. Social media campaigns such as #ILookLikeASurgeon,31 for example, have highlighted longstanding biases and problematic attitudes within surgery, sparking important discussion and change. Understanding the accumulating evidence in the medical literature—and the broad existing evidence in the organisational sciences—that show the deleterious effects of ego driven behaviour may provide even more impetus for this movement and generate more sustainable change. After all, the bulk of surgical education still occurs through informal mentoring and apprenticeship models, as surgeons look to their community of peers and mentors to role model effective behaviour.

The typical surgeon today no doubt possesses an appropriate degree of confidence and self assurance, as well as a healthy level of humility. But as we continue to see cases of behaviour that depart from the normal bounds of confidence, the field at large must reiterate its commitment—in both word and deed—to selecting, training, and maintaining a population of surgeons prepared to act and interact in ways that deliver the best outcomes to patients in the modern healthcare environment. Given the monumental shifts and progress made in just the past few years, the future is bright.