Ethological observations of social behavior in the operating room

A novel approach to forecast surgery durations using machine learning techniques

This study presents a methodology for predicting the duration of surgical procedures using Machine Learning (ML). The methodology incorporates a new set of predictors emphasizing the significance of surgical team dynamics and composition, including experience, familiarity, social behavior, and gender diversity. By applying ML techniques to a comprehensive dataset of over 77,000 surgeries, we achieved a 24% improvement in the mean absolute error (MAE) over a model that mimics the current approach of the decision maker. Our results also underscore the critical role of surgeon experience and team composition dynamics in enhancing prediction accuracy. These advancements can lead to more efficient operational planning and resource allocation in hospitals, potentially reducing downtime in operating rooms and improving healthcare delivery.

"Women's work": Gender and the physician workforce

Historically, the physician professional identity and the organizational structure of Western medicine have been defined by masculine norms such as authority and assertiveness. The past five decades have seen a rapid shift in the demographics of attendees as medical schools, with equal numbers of women and men matriculants for nearly twenty years. Gender as a social, cultural, and structural variable continues to influence the physician workforce. The entry of women into medicine, has had far reaching effects on the expectations of patients, the interactions of physicians with other members of the healthcare team, and the delivery of care. Redefining the culture of medicine to accommodate the diversity of the modern workforce may benefit all physician and improve the delivery of healthcare.

Chronicling the Transition to Competency-Based Medical Education in a Small Subspeciality Program

Background As medical education programs transition to competency-based medical education (CBME), experiences transitioning in the context of small subspecialty programs remain unknown, yet they are needed for effective implementation and continual improvements. Objective To examine faculty and resident experiences transitioning to CBME in a small subspeciality program. Methods Using a qualitative descriptive approach and constructivist lens, faculty and residents in McMaster University's geriatric psychiatry subspecialty program were interviewed about their transition experiences between November 2021 and February 2022, after the program's soft launch of CBME in 2020. Interviews were transcribed and data were analyzed using thematic analysis. Reflexive memo writing and investigator and data triangulation strategies were employed to ensure rigor and trustworthiness of the data. Results Ten of the 17 faculty members (59%) and 3 residents (100%) participated. Six themes were developed: (1) Both faculty and residents see themselves as somewhat knowledgeable about CBME, but sources of knowledge vary; (2) More frequent feedback is beneficial; (3) Aspects of CBME that are challenging for residents are beneficial for faculty; (4) Competence committees are perceived positively despite most participants' limited firsthand experience with them; (5) Small program size is both a barrier and facilitator to providing and receiving feedback; and (6) Suggestions for improvement are centered on helping manage faculty and resident workload imposed by CBME. Conclusions Incongruent expectations surrounding entrustable professional activity management were highlighted as an area requiring support. Collegial relationships among faculty and residents made it difficult for faculty to provide constructive feedback but improved residents' perceptions of the feedback.

Association Between Surgeon/Anesthesiologist Sex Discordance and 1-year Mortality Among Adults Undergoing Noncardiac Surgery: A Population-based Retrospective Cohort Study

OBJECTIVE

To investigate the association between surgeon-anesthesiologist sex discordance and patient mortality after noncardiac surgery.

BACKGROUND

Evidence suggests different practice patterns exist among female and male physicians. However, the influence of physician sex on team-based practices in the operating room and subsequent patient outcomes remains unclear in the context of noncardiac surgery.

METHODS

We conducted a population-based, retrospective cohort study of adult Ontario residents who underwent index, inpatient noncardiac surgery between January 2007 and December 2017. The primary exposure was physician sex discordance (ie, the surgeon and anesthesiologist were of the opposite sex). The primary outcome was 1-year mortality. The association between physician sex discordance and patient outcomes was modeled using multivariable Cox proportional hazard regression with adjustment for relevant physician, patient, and hospital characteristics.

RESULTS

Of 541,209 patients, 158,084 (29.2%) were treated by sex-discordant physician teams. Physician sex discordance was associated with a lower rate of mortality at 1 year [5.2% vs. 5.7%; adjusted HR: 0.95 (0.91-0.99)]. Patients treated by teams composed of female surgeons and male anesthesiologists were more likely to be alive at 1 year than those treated by all-male physician teams [adjusted HR: 0.90 (0.81-0.99)].

CONCLUSIONS

Noncardiac surgery patients had a lower likelihood of 1-year mortality when treated by sex-discordant surgeon-anesthesiologist teams. The likelihood of mortality was further reduced if the surgeon was female. Further research is needed to explore the underlying mechanisms of these observations and design strategies to diversify operating room teams to optimize performance and patient outcomes.

The impact of verbal goal setting on operating room turnover time: a randomized trial

INTRODUCTION AND HYPOTHESIS

Operating room turnover times are highly variable, with longer times having a significant negative impact on hospital costs, surgeon volume, and satisfaction. The primary aim of this randomized trial was to examine the impact of a verbalized time goal on the likelihood of meeting institutional goals.

METHODS

This is a prospective, single-blind, randomized study conducted across four operative sites: inpatient main campus and three outpatient centers. Sequential cases for the same surgeon in the same room were randomized to receive a verbal prompt versus usual care, in which no goal setting was verbalized. Multivariate and univariate statistical analyses were performed.

RESULTS

From July through October 2022, five attending surgeons randomized 88 cases (44 verbal prompt, 44 usual care). Of these, 30 were at the main inpatient hospital. The case mixture included 36% vaginal, 27% endoscopy, 8% open, 10% robotic, and others. Average turnover time was 51.7 and 35.3 min for inpatient and outpatient cases respectively. Overall, only 39.8% of cases hit the institutional turnover time goal. Verbal prompting did not significantly increase the likelihood of achieving the institutional goal (38.4% vs 43.4% p = 0.352) except for in minor surgery (64.0 vs 39.0%, p = 0.0477). A verbal prompt reduced turnover time in major surgery (59.7 vs 47.8 min, p = 0.0445).

CONCLUSION

Our academic center achieved goal turnover times in only 39.8% of cases. Although verbal prompting did not significantly improve the likelihood of meeting institutional goals in the group as a whole, some subgroups were significantly improved.

Strong German Hearts 2023: A Field Report

What do the special forces of the Federal Police and heart surgeons have in common? To find out, a team of the German Society for Thoracic and Cardiovascular Surgery (DGTHG) started a pilot project called "Strong German Hearts" with an intensive 36-hour training supported by the special forces of the Federal Police.

Is There Gender (In)Equality in Pediatric Surgery? An Online Survey on Gender-Related Career Opportunities

INTRODUCTION

 The highest percentage of female surgeons is found in pediatric surgery but most departments are led by men. The aim of this study is to evaluate gender-related career goals, perceived career opportunities, and reasons for differences.

MATERIALS AND METHODS

 An online questionnaire was created and distributed to pediatric surgeons in Germany, Switzerland, and Austria between July and September 2020. Participants were asked to state current position, career goals, and perceived career opportunities in comparison to a colleague of the opposite gender. Reasons for gender-related differences were asked for as free-text comments.

RESULTS

 A total of 182 questionnaires were analyzed. The overall gender ratio was balanced but junior positions were predominantly held by women, while there were more men in leading positions. Most women pursued a position as a consultant, while the majority of men aimed for a leading position. Men mostly regard both genders to have the same career opportunities, whereas most women believe the chances of men to be better. From the free-text answers, three following categories for gender-related differences in career chances were derived: (1) absences due to maternity, (2) differing support and bias arising from gender-related stereotypes, and (3) assumed personality traits.

CONCLUSION

 There are gender-related differences in career opportunities in pediatric surgery. Gender equality is needed not only to overcome injustice but also to maximize team efficiency and collaboration. Career support needs to be gender-independent and (unconscious) bias needs to be recognized and eradicated.

Women as a driver to address gaps in the global surgical workforce

Five billion people around the world lack access to safe and affordable surgical, anaesthetic, and obstetric care. There is a link between countries in which women are underrepresented in the surgical workforce and those struggling to meet their surgical need. In this commentary article, the underrepresentation of women in low- and middle-income country's (LMIC) surgical workforce is discussed. It is argued that the issue is self-reinforcing. On one hand, active change requires a sufficient number of female surgeons to initiate it. On the other, women can only start to penetrate the surgical workforce once they are safe, healthy, and motivated enough to do so, in turn depending on the presence of female surgeons to advocate for their female patients and empower future generations of young girls and women.

Gender equality in national cardiology societies: a cross-sectional study

BACKGROUND

Higher productivity and team stability has been shown for gender diverse teams. However, there is a relevant and well-known gender gap in clinical and academic cardiovascular medicine. So far, no data concerning gender distribution in presidents and executive boards of national cardiology societies exist.

METHODS

In this cross-sectional analysis, gender equality in presidents and representatives of all national cardiology societies, which are members of or affiliated with the European Society of Cardiology (ESC) in 2022 was analyzed. In addition, representatives of the American Heart Association (AHA) were evaluated.

RESULTS

A total of 106 national societies were screened of which 104 were included in the final analysis. Overall, in these 104 societies, 90 out of 106 (85%) presidents were men while 14 (13%) were women. In the analysis of board members and executives, a total of 1128 individuals were included. Overall, 809 (72%) board members were men, 258 (23%) women and 61 (5%) of unknown gender. Except for society presidents in Australia, women were relevantly outnumbered by men in all world regions.

CONCLUSION

Women were globally underrepresented in leading positions of national cardiology societies in all world regions. As national societies are important regional stakeholders, improving gender equality in executive boards might create women role models, help foster careers and narrow the global cardiology gender gap.

Gender Homophily in Interphysician Referrals to Surgeons

INTRODUCTION

The literature on gender homophily has mostly been focused on patient-physician relationship but not on interprofessional referrals. The goal of this study is to quantify interphysician gender homophily of referring physicians in surgical referrals.

METHODS

An observational study of the referral data at a large academic center was performed. Patients referred through Epic to the department of general surgery from January 2016 to October 2019 were included. The primary end point was gender homophily and the primary independent variable was referring physician gender. Gender homophily was defined as greater than expected rates of gender concordance. Gender concordance was defined when referring physicians have the same gender as receiving surgeons. The expected concordance rate was defined as the availability of gender-concordant surgeons in the population. Absolute homophily is the difference between observed and expected concordance rates, whereas relative homophily is the ratio between observed and expected concordance rates.

RESULTS

A total of 25,271 patient referrals from 2625 referring physicians to 91 surgeons were analyzed. The overall observed concordance rate for the entire study population was 55.3% and was 31.7% among female physicians and 82.4% among male physicians. Compared to the expected concordance rate, the absolute gender homophily among all female physicians was +7.2% or a relative homophily of 1.29%. In contrast, the absolute gender homophily among all male physicians was +6.9% or a relative homophily of 1.09%.

CONCLUSIONS

Gender homophily exists in interprofessional referrals. Although referral decisions are presumably based solely on clinical factors, referrals can be affected by subjective biases.

Surgeon Gender and Performance Outcomes for Hysterectomies: Retrospective Cohort Study

STUDY OBJECTIVE

To evaluate whether there are differences in several performance metrics between male and female surgeons for hysterectomies.

DESIGN

Multicenter retrospective cohort study. We matched surgeries performed by female surgeons to those by male surgeons using a propensity score and compared outcomes by gender after adjusting for years in practice and fellowship training.

SETTING

A total of 6 hospitals (3 academic, 3 community) in Ontario, Canada, between July 2016 and December 2019.

PATIENTS

All consecutive patients.

INTERVENTIONS

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was a composite of any complication or return to emergency room (ER) within 30 days. Secondary outcomes were grade II or greater complications, return to ER, and operative time. We included 2664 hysterectomies performed by 77 surgeons. After propensity matching, 963 surgeries performed by females were compared with 963 performed by males. There were no differences in the primary (relative risk [RR], 0.92; 95% confidence interval [CI], 0.71-1.20; p = .56) or secondary outcomes of grade II or greater complication (RR, 1.01; 95% CI, 0.71-1.45; p = .96) or return to ER (RR, 0.81; 95% CI, 0.55-1.20; p = .30). However, surgeries performed by males were 24.72 minutes shorter (95% CI, 18.09-31.34 minutes; p <.001). Entire cohort post hoc regression analysis confirmed these findings. E-value analysis indicated that it is unlikely for an unmeasured confounder to undo the observed difference.

CONCLUSION

Although complication and readmission rates are similar, male surgeons may have a shorter operating time than female surgeons for hysterectomies, which may have implications for health systems and inequalities in surgeon renumeration.

Resident performance in simulation module is associated with operating room performance for laparoscopic cholecystectomy

BACKGROUND

Simulation is an important tool in surgical training. However, the transferability of skills obtained in the simulation setting to the operating room (OR) is uncertain. This study explores the association between resident simulation performance and OR performance in a laparoscopic cholecystectomy (LC) simulation module.

METHODS

A simulation module focused on LC utilizing a virtual reality simulator was completed by general surgery residents. Simulation performance was evaluated using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) and Objective Structured Assessment of Technical Skills (OSATS), as well as a LC-specific simulation assessment form (LC-SIM). Resident subsequent OR performances of LC were measured by the Surgical Training and Assessment Tool (STAT), an online mobile-based evaluation completed by attending surgeons.

RESULTS

Twenty-one residents who completed the simulation module and also with STAT data on LC from 2016 to 2020 were included. Higher scores on incision/port placement on LC-SIM is associated with better tissue handling (coefficient 0.20, p = 0.048) and better time & economy of motion on STAT (coefficient 0.22, p = 0.037). However, higher scores on time and motion on OSATS are associated with worse tissue handling (- 0.28, p = 0.046), worse time & economy of motion (- 0.37, p = 0.009), and worse overall grade (- 0.21, p = 0.044). Higher scores on overall performance on OSATS is associated with worse time & economy of motion (- 0.80, p = 0.008). Higher scores on depth perception on GOALS are associated with worse tissue handling (- 0.28, p = 0.044).

CONCLUSION

We found significant positive and negative associations between resident simulation performance and OR performance, particularly in tissue handling and economy of motion. This could suggest that simulation performance does not reliably predict OR performance. However, this could highlight the concept of excessive caution in the real OR environment and longer operative time which could be interpreted as worse time and economy of motion by the attending surgeons.

Analyzing and Discussing Human Factors Affecting Surgical Patient Safety Using Innovative Technology: Creating a Safer Operating Culture

INTRODUCTION

Surgical errors often occur because of human factor-related issues. A medical data recorder (MDR) may be used to analyze human factors in the operating room. The aims of this study were to assess intraoperative safety threats and resilience support events by using an MDR and to identify frequently discussed safety and quality improvement issues during structured postoperative multidisciplinary debriefings using the MDR outcome report.

METHODS

In a cross-sectional study, 35 standard laparoscopic procedures were performed and recorded using the MDR. Outcome data were analyzed using the automated Systems Engineering Initiative for Patient Safety model. The video-assisted MDR outcome report reflects on safety threat and resilience support events (categories: person, tasks, tools and technology, psychical and external environment, and organization). Surgeries were debriefed by the entire team using this report. Qualitative data analysis was used to evaluate the debriefings.

RESULTS

A mean (SD) of 52.5 (15.0) relevant events were identified per surgery. Both resilience support and safety threat events were most often related to the interaction between persons (272 of 360 versus 279 of 400). During the debriefings, communication failures (also category person) were the main topic of discussion.

CONCLUSIONS

Patient safety threats identified by the MDR and discussed by the operating room team were most frequently related to communication, teamwork, and situational awareness. To create an even safer operating culture, educational and quality improvement initiatives should aim at training the entire operating team, as it contributes to a shared mental model of relevant safety issues.

Reconciliation in human adults: a video-assisted naturalistic observational study of post conflict conciliatory behaviour in interpersonal aggression

Reconciliation is an aspect of conflict resolution, with similar behavioural patterns documented in non-human primates, human children, and human adults of non-Western, non-industrialized cultures. Reconciliation amongst adults of industrialized societies has rarely been studied. We observed naturally occurring conflicts between adults, captured by public security cameras in England. Reconciliation was found in one-quarter of all conflicts and was more prevalent in milder conflicts. Reconciliation typically occurred spontaneously between opponents — and was found within friendship groups and across stranger groups. Reconciliation between opponents also appeared to be stimulated by peers, law enforcement, or shared objects. In some instances, reconciliation extended beyond the initial conflict dyad toward victimized third-party peacemakers. These findings add to growing cross-cultural and cross-species evidence demonstrating the presence and function of post-conflict reconciliation. We extend the repertoire of reconciliatory behaviour and introduce five common features of reconciliation that are central to the study of adult peacemaking.

Implementation of competence by design in Canadian neurosurgery residency programs

OBJECTIVE

The Royal College of Physicians and Surgeons of Canada (RCPSC) recently redesigned the Canadian neurosurgery residency training curriculum by implementing a competency-based model of training known as Competence by Design (CBD) centered around the assessment of Entrustable Professional Activities (EPAs). This sequential explanatory mixed-methods study evaluated potential benefits and pitfalls of CBD in Canadian neurosurgery residency education.

METHODS

Two four-month interval surveys were distributed to all Canadian neurosurgery residents participating in CBD. The surveys assessed important educational components: CBD knowledge of key stakeholders, potential system barriers, and educational/psychological impacts on residents. Paired t-tests were done to assess changes over time. Based on longitudinal survey responses, semi-structured interviews were conducted to investigate in-depth residents' experience with CBD in neurosurgery. The qualitative analysis followed an explanatory approach, and a thematic analysis was performed.

RESULTS

Surveys had 82% average response rate (n = 25). Over time, most residents self-reported that they retrospectively understood concepts around CBD intentions (p = 0.02). Perceived benefits included faculty evaluations with more feedback that was clearer and more objective (53% and 51%). Pitfalls included the amount of time needed to navigate through EPAs (90%) and residents forgetting to initiate EPA forms (71%). There was no significant change over time. During interviews, five key themes were found. Potential solutions identified by residents to enhance their experience included learning analytics data availability, mobile app refinement, and dedicated time to integrate EPAs in the workflow.

CONCLUSION

This study was the first to assess resident-perceived benefits and pitfalls of the neurosurgery CBD training program in an educational framework context. In general, residents believed that theoretical principles behind CBD were valuable, but that technological ability and having enough time to request EPA assessments were significant barriers to success. Long-term studies are required to determine the definitive outcomes of CBD on residents' performance and ultimately, on patient care.

Creating work environments where people of all genders in gynecologic oncology can thrive: An SGO evidence-based review

Equality, equity, and parity in the workplace are necessary to optimize patient care across all aspects of medicine. Gender-based inequities remain an obstacle to quality of care, including within the now majority women subspecialty of gynecologic oncology. The results of the 2020 SGO State of the Society Survey prompted this evidence-based review. Evidence related to relevant aspects of the clinical care model by which women with malignancies are cared for is summarized. Recommendations are made that include ways to create work environments where all members of a gynecologic oncology clinical care team, regardless of gender, can thrive. These recommendations aim to improve equality and equity within the specialty and, in doing so, elevate the care that our patients receive.

Twelve tips for surgeons to maximise medical student learning in the operating theatre

Theatre-based learning is an essential component of undergraduate surgical education and offers a wide range of learning opportunities. However, studies have demonstrated that medical students have not always benefited from this holistic learning environment due to many reasons, including intimidation, hierarchies within the surgical environment and fear of making mistakes. The lead surgical educator's approach is an important influence on the experience and learning of their medical students. These twelve tips are aimed at surgical educators with undergraduate teaching responsibilities. This guidance is based upon evidence from literature and established theories of teaching and learning, supplemented by qualitative interviews with surgeons and medical students. The resulting tips were checked and refined by surgical teaching fellows. These learner-centred tips provide guidance on thorough induction, managing mutual expectations and approaches that optimise teaching and learning in the operating theatre. They are designed to support surgical educators in improving their students' engagement and learning experiences in this setting.

[Professional teamwork and communication in the operating room-A narrative review]

BACKGROUND

A team in the operating room (OR) is a hierarchically structured, gender-mixed group of people belonging to different professional categories. Disparities in the objectives of the different team members under economic pressure to perform, are sources of potential conflict in the daily work routine. This may have a negative impact on patient safety and commercial efficiency of hospital management.

OBJECTIVE

The aim of this summary is to sensitize the reader to the complex of problems in daily life in the OR and to increase awareness of possible approaches to solve the difficulties in an OR. Problem solutions might be approached by improvement of communication and team building.

METHODS

Narrative review of current literature and expert recommendations by a literature search in PubMed and Medline; keywords included teamwork, communication, operating room, team building.

RESULTS AND CONCLUSION

Communication and teamwork in the OR are of immense importance for patient safety and the economic development of a hospital. Improvements in communication structure, among other things due to the implementation of a team time out and moderation from outside (OR manager) offer solutions to avoid conflicts in everyday clinical practice.

How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis

BACKGROUND

Despite substantial implications for healthcare provider practice and patient outcomes, gender has yet to be systematically explored with regard to interprofessional operating room (OR) teamwork. We aimed to explore and describe how gender and additional social identity factors shape experiences and perceptions of teamwork in the OR.

METHODS

This study was a qualitative secondary analysis of semi-structured interviews with OR team members conducted between November 2018 and July 2019. Participants were recruited across hospitals in Ontario, Canada. We conducted both purposive and snowball sampling until data saturation was reached. Transcripts were analyzed thematically by two independent research team members, moving from open to axial coding.

RESULTS

Sixty-six interviews of OR healthcare professionals were completed: anesthesia (n=17), nursing (n=19), perfusion (n=2), and surgery (n=26). Traditional gender roles, norms, and stereotypes were perceived and experienced by both women and men, but with different consequences. Both women and men participants described challenges that women face in the OR, such as being perceived negatively for displaying leadership behaviours. Participants also reported that interactions and behaviours vary depending on the team gender composition, and that other social identities, such as age and race, often interact with gender. Nevertheless, participants indicated a belief that the influence of gender in the OR may be modified.

CONCLUSIONS

The highly gendered reality of the OR creates an environment conducive to breakdowns in communuication and patient safety risks in addition to diminishing team morale, psychological safety, and provider well-being. Consequently, until teamwork interventions adequately account for gender, they are unlikely to be optimally effective or sustainable.

Opportunities and Barriers to Rural Telerobotic Surgical Health Care in 2021: Report and Research Agenda from a Stakeholder Workshop

Background: There are well-recognized challenges to delivering specialty health care in rural settings. These challenges are particularly evident for specialized surgical health care due to the lack of trained operators in rural communities. Telerobotic surgery could have a significant impact on the rural-urban health care gap, but thus far, the promise of this method of health care delivery has gone unrealized. With the increasing adoption of telehealth over the past year, along with the maturation of telecommunication and robotic technologies over the past 2 decades, a reappraisal of the opportunities and barriers to widespread implementation of telerobotic surgery is warranted. Here we report the outcome of a rural telerobotic stakeholder workshop to explore modern-day issues critical to the advancement of telerobotic surgical health care. Materials and Methods: We assembled a multidisciplinary stakeholder panel to participate in a 2-day Rural Telerobotic Surgery Stakeholder Workshop. Participants had diverse expertise, including specialty surgeons, technology experts, and representatives of the broader telerobotic health care ecosystem, including economists, lawyers, regulatory consultants, public health advocates, rural hospital administrators, nurses, and payers. The research team reviewed transcripts from the workshop with themes identified and research questions generated based on stakeholder comments and feedback. Results: Stakeholder discussions fell into four general themes, including (1) operating room team interactions, (2) education and training, (3) network and security, and (4) economic issues. The research team then identified several research questions within each of these themes and provided specific research strategies to address these questions. Conclusions: There are still important unanswered questions regarding the implementation and adoption of rural telerobotic surgery. Based on stakeholder feedback, we have developed a research agenda along with suggested strategies to address outstanding research questions. The successful execution of these research opportunities will fill critical gaps in our understanding of how to advance the widespread adoption of rural telerobotic health care.

Autonomy in the Operating Room: A Multicenter Study of Gender Disparities During Surgical Training

BACKGROUND

Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied.

OBJECTIVE

To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance.

METHODS

From September 2015 to May 2019, attending surgeons and trainees from 71 programs assessed trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale after surgical procedures. Multivariable regression models were used to examine the association of trainee gender with autonomy and performance evaluations.

RESULTS

A total of 3255 trainees and attending surgeons completed 94 619 evaluations. Attendings gave lower ratings of operative autonomy to female trainees than male trainees when controlling for training level, attending, and surgical procedure (effect size B = -0.0199, P = .008). There was no difference in ratings of autonomy at the beginning of training (P = .32); the gap emerged as trainees advanced in years (B = -0.0163, P = .020). The gender difference in autonomy was largest for the most complex cases (B = -0.0502, P = .002). However, there was no difference in attending ratings of surgical performance for female trainees compared to male trainees (B = -0.0124, P = .066). Female trainees rated themselves as having less autonomy and worse performance than males when controlling for training level, attending, procedure, case complexity, and attending ratings (autonomy B = -0.0669, P < .001; performance B = -0.0704, P < .001).

CONCLUSIONS

While there was no significant difference in ratings of operative performance, a small difference between ratings of operative autonomy for female and male surgical trainees was identified.

The impact of team familiarity on intra and postoperative cardiac surgical outcomes

BACKGROUND

Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes.

METHODS

Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary-an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata.

RESULTS

Median (interquartile range) cardiopulmonary bypass duration was 132 (91-192) minutes, and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (-24 minutes) and high-risk (-27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality.

CONCLUSION

Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.

Impact of surgeon and anaesthesiologist sex on patient outcomes after cardiac surgery: a population-based study

BACKGROUND

Effective teamwork between anaesthesiologists and surgeons is essential for optimising patient safety in the cardiac operating room. While many factors may influence the relationship between these two physicians, the role of sex and gender have yet to be investigated.

OBJECTIVES

We sought to determine the association between cardiac physician team sex discordance and patient outcomes.

DESIGN

We performed a population-based, retrospective cohort study.

PARTICIPANTS AND SETTING

Adult patients who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral or tricuspid valve surgery between 2008 and 2018 in Ontario, Canada.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause 30-day mortality. Secondary outcomes included major adverse cardiovascular events at 30 days and hospital and intensive care unit lengths of stay (LOS). Mixed effects logistic regression was used for categorical outcomes and Poisson regression for continuous outcomes.

RESULTS

79 862 patients underwent cardiac surgery by 98 surgeons (11.2% female) and 279 anaesthesiologists (23.3% female); 19 893 (24.9%) were treated by sex-discordant physician teams. Physician sex discordance was not associated with overall patient mortality or LOS; however, patients who underwent isolated CABG experienced longer hospital LOS when treated by an all-male physician team as compared with an all-female team (adjusted OR=1.07; p=0.049). When examining the impact of individual physician sex, the length of hospital stay was longer when isolated CABG procedures were attended by a male surgeon (OR=1.10; p=0.004) or anaesthesiologist (OR=1.02; p=0.01).

CONCLUSIONS

Patient mortality and length of stay after cardiac surgery may vary by sex concordance of the attending surgeon-anaesthesiologist team. Further research is needed to examine the underlying mechanisms of these observed relationships.

The DISCO study-Does Interventionalists' Sex impact Coronary Outcomes?

OBJECTIVES

To examine the association of operator sex with appropriateness and outcomes of percutaneous coronary intervention (PCI).

BACKGROUND

Recent studies suggest that physician sex may impact outcomes for specific patient cohorts. There are no data evaluating the impact of operator sex on PCI outcomes.

METHODS

We studied the impact of operator sex on PCI outcome and appropriateness among all patients undergoing PCI between January 2010 and December 2017 at 48 non-federal hospitals in Michigan. We used logistic regression models to adjust for baseline risk among patients treated by male versus female operators in the primary analysis.

RESULTS

During this time, 18 female interventionalists and 385 male interventionalists had performed at least one PCI. Female interventionalists performed 6362 (2.7%) of 239,420 cases. There were no differences in the odds of mortality (1.48% vs. 1.56%, adjusted OR [aOR] 1.138, 95% CI: 0.891-1.452), acute kidney injury (3.42% vs. 3.28%, aOR 1.027, 95% CI: 0.819-1.288), transfusion (2.59% vs. 2.85%, aOR 1.168, 95% CI: 0.980-1.390) or major bleeding (0.95% vs. 1.07%, aOR 1.083, 95% CI: 0.825-1.420) between patients treated by female versus male interventionalist. While the absolute differences were small, PCIs performed by female interventional cardiologists were more frequently rated as appropriate (86.64% vs. 84.45%, p-value <0.0001). Female interventional cardiologists more frequently prescribed guideline-directed medical therapy.

CONCLUSIONS

We found no significant differences in risk-adjusted in-hospital outcomes between PCIs performed by female versus male interventional cardiologists in Michigan. Female interventional cardiologists more frequently performed PCI rated as appropriate and had a higher likelihood of prescribing guideline-directed medical therapy.

Ethics Consultation in Surgical Specialties

Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.

Women Surgeons' Perspectives on System-level Strategies to Address Interpersonal Workplace Conflict

OBJECTIVE

We sought to gain a comprehensive understanding of the current methods for conflict resolution and the ways in which women surgeons would prefer workplace conflicts to be adjudicated.

SUMMARY OF BACKGROUND DATA

Interprofessional workplace conflicts are poorly studied, particularly for women in surgery. These conflicts may negatively impact surgical team dynamic and be detrimental to patient safety. Moreover, workplace conflicts and their management are a proposed driver of decreased professional satisfaction and achievement. How women surgeons experience workplace conflicts and how these are managed remains unexplored.

METHODS

We conducted 30 semi-structured interviews with women surgeons across the United States who had experienced workplace conflict that resulted in action by a nonphysician. Surgeons were diverse with respect to demographics, specialty, and institutional settings. Through thematic analysis using NVivo, we analyzed and reported patterns within the data.

RESULTS

Although the majority of women asserted resilience in how they engage with these situations, many also cited ways in which these events could better be adjudicated. Recommendations included (1) more direct conflict resolution, (2) more transparency in reporting processes, (3) greater opportunity to address complaints, (4) explicit policies for events that repeatedly result in workplace conflict, and (5) divorcing interpersonal complaints from patient safety reporting mechanisms.

CONCLUSION

This study motivates and informs best practices around adjudication of workplace conflict to help protect women surgeons and nonclinicians. Going forward, best practices should include more objective criteria for how conflicts are adjudicated. Continued efforts at an institutional level are needed to help mitigate inequities against women surgeons.

Achieving and Maintaining Safety in Healthcare Requires Unwavering Institutional and Individual Commitments

In 2000, "To Err Is Human" brought to light the fact that the estimated number of people dying from medical errors occurring in hospitals exceeded those that die from motor vehicle accidents (MVAs), breast cancer, or acquired immunodeficiency syndrome (AIDS) - three causes receiving far more public attention. The report prompted the gradual adoption of safety processes developed in the nuclear and aviation industries. However, sophisticated engineering solutions to operations are not enough. High and low mortality hospitals have similar processes and procedures, but low-mortality hospitals are more proficient at recognizing and managing serious complications as they unfold. This ability to rescue a deteriorating situation (resilience) reflects a healthier safety culture. Organizations move within the safety space in the direction of either more or less resilience depending on the fluctuation of their safety culture. Improving resilience requires transforming learned safety practices into a "habit" in conjunction with accepting accountability. Personal accountability means commitment to safe practices along with effective and transparent reporting of near misses/close calls and adverse events (AEs). Institutional accountability means putting safety first by ensuring the availability of appropriate resources, role leadership modeling, and effective management of sentinel events (SEs) to reduce harm occurrence and re-occurrence. This requires a more robust root cause analysis (RCA) process to guarantee that action plans produce strong and effective corrective measures. Synergistic coaching interventions include instilling the awareness that failure can and will happen, mapping team talents, and assessing gaps. These interventions will optimize group expertise, reaffirming the concept of institutional and personal accountability. The unending performance of drills will sustain the group resilience under both expected and unexpected conditions. Given the strong correlation between practice environment and outcomes, sustained improvement of the safety climate will produce more robust safety behaviors and ultimately better outcomes.

Sex Diversity in the Cardiothoracic Anesthesiology Fellowship: The Influence of Geographic Region

OBJECTIVES

To investigate if the lack of sex diversity in adult cardiothoracic anesthesiology fellowships is a result of few female applicants or low acceptance rate.

DESIGN

Retrospective review of adult cardiothoracic anesthesiology applicants and fellows by sex and geographic regions across the United States.

SETTING

Accreditation Council for Graduate Medical Education's adult cardiothoracic anesthesiology fellowship programs across the United States.

PARTICIPANTS

Applicants to adult cardiothoracic anesthesiology fellowship programs and fellows.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

Numerical comparison of male and female applicants by percentage and acceptance rates into adult cardiothoracic anesthesiology fellowship programs in each geographic region. Women comprised between 27% and 35% of applicants from 2013 to 2018. Acceptance rates for men completing residency in the Midwest region ranged between 67% and 84%, and 67% and 87% for women from the Midwest (p = 0.1-0.9). Men from Northeast residencies had acceptance rate of 71% to 86% and women had rate of 69% to 83% (p = 0.2-0.8). Male and female residents from the Southeast had acceptance rates of 65% to 94% and 71% to 93%, respectively (p = 0.3-0.8). The male residents from the Southwest had acceptance rates of 73% to 85%, and female residents had rates between 44% and 100% (p = 0.02-0.8). The male residents from the West had rates of 59% to 88%, female residents had rates between 64% and 100% (p = 0.1-0.7).

CONCLUSIONS

There is an absence of clear identification of the barriers preventing women from entering cardiac anesthesiology. The reasons leading to a male-dominated field of cardiac anesthesiologists stem from fewer female anesthesiology residents applying to cardiothoracic anesthesiology fellowships. No bias against acceptance of women into cardiothoracic anesthesiology fellowships was found.

Has a critical mass of women resulted in gender equity in gynecologic surgery?

Gender equity in medicine and surgery has recently received widespread attention. Unlike surgical specialties that remain predominantly male, the majority of obstetrician-gynecologists have been women for nearly a decade, and women have composed the majority of trainees since the 1990s. Despite a critical mass of women, biases related to gender persist in the field. Professional and behavioral expectations of men and women gynecologists remain different for patients and workplace colleagues. Gender discrimination and sexual harassment are still experienced at high rates by both trainees and obstetrician-gynecologists in practice. In addition, in other surgical fields, women gynecologic surgeons face a gender wage gap that is unexplained by differences in experience, hours worked, or subspecialty training. Academic advancement and the attainment of leadership positions remain a challenge for many women. Policies related to pregnancy and parenting may disproportionately affect the careers of women gynecologists. This article presents peer-reviewed evidence relevant to gender equity in the workplace and suggests proactive interventions to ensure diversity and inclusion for gynecologic surgeons.

Women Surgeons' Experiences of Interprofessional Workplace Conflict

IMPORTANCE

Gender differences in interprofessional conflict may exist and precipitate differential achievement, wellness, and attrition in medicine.

OBJECTIVE

Although substantial attention and research has been directed toward improving gender equity in surgery and addressing overall physician wellness, research on the role of interprofessional conflict has been limited. The objective of this study was to understand scenarios driving interprofessional conflict involving women surgeons, the implications of the conflict on personal, professional, and patient outcomes, and how women surgeons navigate conflict adjudication.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative approach was used to explore the nature, implications, and ways of navigating interprofessional workplace conflict experienced by women surgeons. The setting was a national sample of US women surgeons. Purposive and snowball sampling were used to recruit women surgeons in training or practice from annual surgical society meetings. Participants were eligible if they were currently in a surgical training program or surgical practice. Nearly all participants had experienced at least 1 workplace conflict with a nonphysician staff member resulting in a formal write-up.

EXPOSURES

A workplace conflict was defined as any conflict resulting in the nonphysician staff member taking action such as confronting the woman surgeon, reporting the event to supervisors, or filing a formal report.

MAIN OUTCOMES AND MEASURES

Interviews were conducted between February 19, 2019, and June 21, 2019. Recordings were transcribed and deidentified. Inductive thematic analysis was used to examine data in relation to the research questions.

RESULTS

Thirty US women surgeons (8 [27%] age 25-34 years, 16 [53%] age 35-44 years, 5 [17%] age 45-54 years, and 1 [3%] age 55-64 years) of varying surgical specialties were interviewed. Conflicts were often reported as due to a breakdown in communication or from performance-related disputes. Participants perceived personal and professional implications including self-doubt, depression, frustration, anxiety, loss of sleep, reputational harms, and delays to advancement. Participants also described potential patient safety implications primarily due to decreased communication resulting from some surgeons being hesitant to engage in subsequent interactions. Participants described a variety of navigation strategies including relationship management, rapport building, and social capital. The success of these processes tended to vary by individual circumstances, including the details of the conflict, practice setting, level of support of leadership, and individual personality of the surgeon.

CONCLUSIONS AND RELEVANCE

This qualitative study highlights women surgeons' experiences with interprofessional workplace conflict. Interprofessional culture building, broader dissemination of implicit bias training, and transparent and equitable adjudication systems are potential strategies for avoiding or mitigating the implications of these conflicts.

Impact of physician's sex/gender on processes of care, and clinical outcomes in cardiac operative care: a systematic review

OBJECTIVES

This systematic review aimed to assess the role of physician's sex and gender in relation to processes of care and/or clinical outcomes within the context of cardiac operative care.

DESIGN

A systematic review.

DATA SOURCES

Searches were conducted in PsycINFO, Embase and Medline from inception to 6 September 2018. The reference lists of relevant systematic reviews and included studies were also searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Quantitative studies of any design were included if they were published in English or French, involved patients of any age undergoing a cardiac surgical procedure and specifically assessed differences in processes of care or clinical patient outcomes by physician's sex or gender. Studies were screened in duplicate by two pairs of independent reviewers.

OUTCOME MEASURES

Processes of care, patient morbidity and patient mortality.

RESULTS

The search yielded 2095 publications after duplicate removal, of which two were ultimately included. These studies involved various types of surgery, including cardiac. One study found that patients treated by female surgeons compared with male surgeons had a lower 30-day mortality. The other study, however, found no differences in patient outcomes by surgeon's sex. There were no studies that investigated anaesthesiologist's sex/gender. There were also no studies investing physician's sex or gender exclusively in the cardiac operating room.

CONCLUSIONS

The limited data surrounding the impact of physician's sex/gender on the outcomes of cardiac surgery inhibits drawing a robust conclusion at this time. Results highlight the need for primary research to determine how these factors may influence cardiac operative practice, in order to optimise provider's performance and improve outcomes in this high-risk patient group.

Effects of Gender and Race/Ethnicity on Perioperative Team Performance

We judge each other every day using demographic characteristics (such as gender and race/ethnicity), and these social identities shape our lives in profound ways. The impacts of demographic diversity in perioperative teams are poorly understood, and mixed results are reported in other team-based work settings. Drawing from decades' worth of organizational behavior literature, the authors propose a model of critical factors related to interplays between diversity, communication, and conflict, all which take place in a hierarchical environment influenced by power differences. Evidence-based recommendations are provided, aimed at maximizing benefits of diversity in perioperative teams while minimizing negative consequences.

Elsa as Horse Whisperer in Disney’s Frozen 2: Opportunity “Nokk”s to Quash Gender Stereotypes

Frozen 2 (2019) provided Disney with the opportunity to move past discomfort about the confluence of women’s sexuality and power in Queen Elsa portrayed in Frozen (2013). Yet in Frozen 2, Elsa remains romantically unattached, despite audience interest in her love life in the six years following the release of Frozen. In Frozen 2, Elsa forms a bond with a mythological male horse, a Nokk, whom she first battles, and then tames, showcasing her horse-whispering talents while building intimacy with the equine. The symbolism of Elsa’s domestication of the willful Nokk relates to the gynocentric horse and pony genre that explores girls’ desire for intimacy within a fictional world. In Frozen 2, however, substituting a male horse for a relationship with a human allows Disney to sidestep two potential controversies: (1) a queer love interest for Elsa, and (2) the portrayal of Elsa as wielding more power than a non-magically endowed male partner. In addition, Elsa’s taming of the horse in Frozen 2 places her in the realm of equestrianism, a woman-dominated sport where femininity is nevertheless devalued. As a result, her skills as a horse whisperer do not threaten men’s ascendancy, reflecting real-life gender dynamics in equestrian sport. These themes show how Disney balked at modernizing Elsa, retreating to outdated conceptions of gender roles rather than depicting progressive gender dynamics and sexuality in Disney royalty.

How Approaches to Animal Swarm Intelligence Can Improve the Study of Collective Intelligence in Human Teams

Researchers of team behavior have long been interested in the essential components of effective teamwork. Much existing research focuses on examining correlations between team member traits, team processes, and team outcomes, such as collective intelligence or team performance. However, these approaches are insufficient for providing insight into the dynamic, causal mechanisms through which the components of teamwork interact with one another and impact the emergence of team outcomes. Advances in the field of animal behavior have enabled a precise understanding of the behavioral mechanisms that enable groups to perform feats that surpass the capabilities of the individuals that comprise them. In this manuscript, we highlight how studies of animal swarm intelligence can inform research on collective intelligence in human teams. By improving the ability to obtain precise, time-varying measurements of team behaviors and outcomes and building upon approaches used in studies of swarm intelligence to analyze and model individual and group-level behaviors, researchers can gain insight into the mechanisms underlying the emergence of collective intelligence. Such understanding could inspire targeted interventions to improve team effectiveness and support the development of a comparative framework of group-level intelligence in animal and human groups.

Gender-based pairings influence cooperative expectations and behaviours

The study explores the expectations and cooperative behaviours of men and women in a lab-in-the-field experiment by means of citizen science practices in the public space. It specifically examines the influence of gender-based pairings on the decisions to cooperate or defect in a framed and discrete Prisoner's Dilemma game after visual contact. Overall, we found that when gender is considered behavioural differences emerge in expectations of cooperation, cooperative behaviours, and their decision time depending on whom the partner is. Men pairs are the ones with the lowest expectations and cooperation rates. After visual contact women infer men's behaviour with the highest accuracy. Also, women take significantly more time to defect than to cooperate, compared to men. Finally, when the interacting partners have the opposite gender they expect significantly more cooperation and they achieve the best collective outcome. Together, the findings suggest that non verbal signals may influence men and women differently, offering novel interpretations to the context-dependence of gender differences in social decision tasks.

"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams

BACKGROUND

Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team.

METHODS AND FINDINGS

The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators.

CONCLUSIONS

Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

Regional, institutional, and departmental factors associated with gender diversity among BS-level chemical and electrical engineering graduates

Engineering remains the least gender diverse of the science, technology, engineering and mathematics fields. Chemical engineering (ChE) and electrical engineering (EE) are exemplars of relatively high and low gender diversity, respectively. Here, we investigate departmental, institutional, and regional factors associated with gender diversity among BS graduates within the US, 2010-2016. For both fields, gender diversity was significantly higher at private institutions (p < 1x10-6) and at historically black institutions (p < 1x10-5). No significant association was observed with gender diversity among tenure-track faculty, PhD-granting status, and variations in departmental name beyond the standard "chemical engineering" or "electrical engineering". Gender diversity among EE graduates was significantly decreased (p = 8x10-5) when a distinct degree in computer engineering was available; no such association was observed between ChE gender diversity and the presence of biology-associated degrees. States with a highly gender diverse ChE workforce had a significantly higher degree of gender diversity among BS graduates (p = 3x10-5), but a significant association was not observed for EE. State variation in funding of support services for K-12 pupils significantly impacted gender diversity of graduates in both fields (p < 1x10-3), particularly in regards to instructional staff support (p < 5x10-4). Nationwide, gender diversity could not be concluded to be either significantly increasing or significantly decreasing for either field.

Exploring group boundaries and conflicts: a social identity theory perspective

CONTEXT

In the clinical environment, health care professionals self-categorise into different groups towards which they develop positive attitudes, whereas they view other groups less favourably. Social identity theory purports that these attitudes influence group processes and may foster conflicts that impede collaborative practice, although this relationship is poorly understood. This study used concepts from social identity theory to examine the interplay between group processes and conflicts, as well as the consequences of these conflicts, with the goal of identifying educational strategies to favour teamwork.

METHODS

Semi-structured interviews with 82 randomly selected physicians and nursing professionals working at a Swiss academic medical centre explored participants' experiences of conflicts. Data analysis was informed by social identity theory and focused on interviews where group processes were highlighted by participants. The analysis sought to uncover how group processes were intertwined with conflicts and how they affected health care professionals.

RESULTS

A total of 42 participants out of the initial pool of 82 interviews shared 52 stories of conflicts involving group processes. Most of these stories were shared by physicians and involved groups of physicians at different hierarchical levels. Conflicts and group processes were linked in two ways: (i) through processes of group membership when individuals struggled to join a relevant group, and (ii) through intergroup boundaries, such as when participants perceived that power differentials disadvantaged their own groups. Conflicts could lead to difficult experiences for clinicians who questioned their abilities, became disillusioned with their professional ideals and developed negative perceptions of other groups.

CONCLUSIONS

This study suggests that conflicts involving group processes may lead to stronger intergroup boundaries, challenging current educational efforts to favour teamwork in health care. Taking steps to create more inclusive groups and to encourage perspective taking may help manage intergroup conflict.