Vascular Surgery Curriculum for Medical Students: A National Targeted Needs Assessment.

BACKGROUND: At present, neither the American College of Surgeons (ACS) nor the Society for Vascular Surgery (SVS) provides curriculum recommendations for medical students rotating on a vascular surgery service. We sent a targeted needs assessment to vascular surgeons across the country in order to investigate the need for a structured curriculum for medical students participating in a vascular surgery rotation during their clinical clerkships. METHODS: The survey was developed with input from medical students, vascular surgeons, and medical educators. Respondents were identified from the Fellowship and Residency Electronic Interactive Database (FREIDA). The needs assessment was sent to program directors of vascular residencies and fellowships and to other vascular surgery educators. The survey collected data regarding the existing vascular surgery curriculum at the respondent's institution, the need for a standardized curriculum, desired experiences for medical students, and important vascular topics for medical students to cover while on rotation. RESULTS: Responses were obtained from 50 of the 146 surveyed individuals (response rate = 34.2%). 48 respondents (96%) worked in an academic hospital or academic affiliated hospital. With regard to the existing vascular surgery curriculum, only 28 respondents (61%) indicated that they had a curriculum approved by the surgery clerkship director. 37 respondents (77.1%) said there were at least goals and objectives for students on the vascular surgery service, and 29 respondents (60.4%) indicated that there was dedicated time for didactic sessions. Only 17 respondents (35.4%) indicated students gave a case presentation on the service. 29 respondents (63%) agreed or strongly agreed that there should be a standardized vascular curriculum for medical students. When asked to rank 9 topics from most important to least important for students to learn, respondents ranked peripheral arterial disease, aortic disease, and carotid disease highest. Simulation experience was most frequently indicated as a desired addition to the curriculum, and only 16 respondents (33.3%) reported opportunities for vascular surgery specific simulation experiences. CONCLUSIONS: This study identified the lack of an existing structured curriculum for medical students, the desire for a standardized curriculum, and key topics and experiences that are felt to be important for students to cover.  With this information in hand, vascular educators have the potential to enhance the learning experience of medical students rotating through the service by developing a standardized curriculum.

The RGD sequence present in IGFBP-2 is required for reduced glucose clearance after oral glucose administration in female transgenic mice.

Recent studies suggest that insulin-like growth factor-binding protein-2 (IGFBP-2) affects both growth and metabolism. Whereas negative growth effects are primarily due to negative interference with IGF-I, the mechanisms for metabolic interference of IGFBP-2 are less clear. As we demonstrate, overexpression of IGFBP-2 in transgenic mice is correlated with a decelerated clearance of blood glucose after oral administration. IGFBP-2 carries an integrin-binding domain (RGD motif), which has been shown to also mediate IGF-independent effects. We thus asked if higher serum levels of IGFBP-2 without an intact RGD motif would also partially block blood glucose clearance after oral glucose application. In fact, transgenic mice overexpressing mutated IGFBP-2 with higher levels of IGFBP-2 carrying an RGE motif instead of an RGD were not characterized by decelerated glucose clearance. Impaired glucose tolerance was correlated with lower levels of GLUT4 present in plasma membranes isolated from muscle tissues after glucose challenge. At the same time, activation of TBC1D1 was depressed in mice overexpressing wild-type but not mutated IGFBP-2. Although we do not have reason to assume altered activation of IGF-I receptor or PDK1/Akt activation in both models, we have identified increased levels of integrin-linked kinase and focal adhesion kinase dependent on the presence of the RGD motif. From our results we conclude that impaired glucose clearance in female IGFBP-2 transgenic mice is dependent on the presence of the RGD motif and that translocation of GLUT4 in the muscle may be regulated by IGFBP-2 via RGD-dependent mechanisms.

Resection of intracaval leiomyomatosis using abdominal approach and venovenous bypass.

BACKGROUND: Intravenous leiomyomatosis is the venous involvement of a histologically benign uterine tumor. This uncommon tumor can present contemporaneously with the primary uterine tumor or in a delayed fashion. Tumor extends up the venous system, via the iliac or ovarian veins, and can involve portions or all of the inferior vena cava and can extend into the heart as well. Complete resection of this tumor is the therapeutic goal. Previous reports have described the use of combined thoracic and abdominal approaches, cardiopulmonary bypass, circulatory arrest, and a single report of an entirely abdominal approach to resection without bypass. METHODS AND RESULTS: We present a review of the existing literature describing surgical intervention for intravenous leiomyomatosis and describe two cases of tumor extending up the intra-abdominal vena cava. Using venovenous bypass without need for thoracotomy, we were able to resect both tumors with minimal blood loss and no hemodynamic instability. CONCLUSIONS: We suggest that venovenous bypass is an excellent tool in resection of these tumors and should be considered for many cases in lieu of full cardiopulmonary bypass or circulatory arrest.

Teaching operating room conflict management to surgeons: clarifying the optimal approach.

CONTEXT: Conflict management has been identified as an essential competence for surgeons as they work in operating room (OR) teams; however, the optimal approach is unclear. Social science research offers two alternatives, the first of which recommends that task-related conflict be managed using problem-solving techniques while avoiding relationship conflict. The other approach advocates for the active management of relationship conflict as it almost always accompanies task-related conflict. Clarity about the optimal management strategy can be gained through a better understanding of conflict transformation, or the inter-relationship between conflict types, in this specific setting. The purpose of this study was to evaluate conflict transformation in OR teams in order to clarify the approach most appropriate for an educational conflict management programme for surgeons. METHODS: A constructivist grounded theory approach was adopted to explore the phenomenon of OR team conflict. Narratives were collected from focus groups of OR nurses and surgeons at five participating centres. A subset of these narratives involved transformation between and within conflict types. This dataset was analysed. RESULTS: The results confirm that misattribution and the use of harsh language cause conflict transformation in OR teams just as they do in stable work teams. Negative emotionality was found to make a substantial contribution to responses to and consequences of conflict, notably in the swiftness with which individuals terminated their working relationships. These findings contribute to a theory of conflict transformation in the OR team. CONCLUSIONS: There are a number of behaviours that activate conflict transformation in the OR team and a conflict management education programme should include a description of and alternatives to these behaviours. The types of conflict are tightly interwoven in this setting and thus the most appropriate management strategy is one that assumes that both types of conflict will exist and should be managed actively.

Quiescent-interval single-shot unenhanced magnetic resonance angiography of peripheral vascular disease: Technical considerations and clinical feasibility.

We performed technical optimization followed by a pilot clinical study of quiescent-interval single-shot MR angiography for peripheral vascular disease. Quiescent-interval single-shot MR angiography acquires data using a modified electrocardiographic (ECG)-triggered, fat suppressed, two-dimensional, balanced steady-state, free precession pulse sequence incorporating slice-selective saturation and a quiescent interval for maximal enhancement of inflowing blood. Following optimization at 1.5 T, a pilot study was performed in patients with peripheral vascular disease, using contrast-enhanced MR angiography as the reference standard. The optimized sequence used a quiescent interval of 228 ms, alpha/2 catalyzation of the steady-state magnetization, and center-to-out partial Fourier acquisition with parallel acceleration factor of 2. Spatial resolution was 2-3mm along the slice direction and 0.7-1mm in-plane before interpolation. Excluding stented arterial segments, the sensitivity, specificity, and positive and negative predictive values of quiescent-interval single-shot MR angiography for arterial narrowing greater than 50% or occlusion were 92.2%, 94.9%, 83.9%, and 97.7%, respectively. Quiescent-interval single-shot MR angiography provided robust depiction of normal peripheral arterial anatomy and peripheral vascular disease in less than 10 min, without the need to tailor the technique for individual patients. Moreover, the technique provides consistent image quality in the pelvic region despite the presence of respiratory and bowel motion.

Resident Perspectives on Teaching During Awake Surgical Procedures.

INTRODUCTION: Residents learn technical and communication skills during training and practice both concurrently during awake surgical procedures. Patients have expressed mixed views on resident involvement in their surgical care, making this context challenging for residents to navigate. We sought to qualitatively explore resident perspectives on teaching during awake surgical procedures. METHODS: Residents in Urology, Obstetrics and Gynecology, and General Surgery who had been exposed to 10 or more awake surgical procedures were recruited for recorded focus groups at the University of Chicago. Recordings were transcribed, coded, and reviewed by 3 researchers using the constant comparative method until thematic saturation was reached. RESULTS: Twenty-five residents participated in 5 focus groups. Residents identified positive educational techniques during awake surgery including preprocedural communication, explaining teaching and the resident role, whispering/nonverbal communication, involving the patient in education, and confident educator. Residents described challenges and failures in education, including hesitating to ask questions, hesitating to correct a learner, whispering/nonverbal communication, and taking over. In discussing informed consent during awake procedures, some residents described that the consent process should or did change during awake procedures, for example, to include more information about the resident role. CONCLUSIONS: Residents participating in awake surgical procedures offer new insights on successful techniques for teaching during awake surgery, emphasizing that good communication in the procedure room starts beforehand. They also identify challenges with teaching in this context, often related to a lack of open and clear communication.

Moving skills training closer to application: In-rotation skills curriculum is feasible and effective.

PURPOSE: Using simulation can help surgical trainees acquire surgical skills but at the expense of clinical learning time. We postulate an in-rotation skills curriculum is feasible and minimizes time away from clinical experiences. METHODS: Surgical residents (PGY2-5) were allotted two hours of weekly protected time for rotation specific simulation modules that included assessment, mentoring, and practice. Between September 2015 and February 2016 performance data was collected and participants were surveyed. RESULTS: Completion rates of 87-100% were achieved and post-test scores improved significantly, indicating improved performance. The survey (29/30 RR) revealed that 81.5% felt 2 hours a week was 'just right' and 79.3% agreed or strongly agreed the in-rotation aspect was a benefit. Improved confidence in the OR was reported by 86.2% of residents Intra-operative skill was self-assessed as improved in 79.3%. CONCLUSION: In-rotation skills curriculum with high completion rates is feasible and allows training in close proximity to clinical application. Performance in the simulated environment significantly improved with corresponding improvements in confidence and self-assessed skill in the operating room.

Bridging the Gap: Interdepartmental Quality Improvement and Patient Safety Curriculum Created by Hospital Leaders, Faculty, and Trainees.

BACKGROUND: The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review recommends that quality improvement/patient safety (QI/PS) experts, program faculty, and trainees collectively develop QI/PS education. OBJECTIVE: Faculty, hospital leaders, and resident and fellow champions at the University of Chicago designed an interdepartmental curriculum to train postgraduate year 1 (PGY-1) residents on core QI/PS principles, measuring outcomes of knowledge, attitudes, and event reporting. METHODS: The curriculum consisted of 3 sessions: PS, quality assessment, and QI. Faculty and resident and fellow leaders taught foundational knowledge, and hospital leaders discussed institutional priorities. PGY-1 residents attended during protected conference times, and they completed in-class activities. Knowledge and attitudes were assessed using pretests and posttests; graduating residents (PGY-3-PGY-8) were controls. Event reporting was compared to a concurrent control group of nonparticipating PGY-1 residents. RESULTS: From 2015 to 2017, 140 interns in internal medicine (49%), pediatrics (33%), and surgery (13%) enrolled, with 112 (80%) participating and completing pretests and posttests. Overall, knowledge scores improved (44% versus 57%, P < .001), and 72% of residents demonstrated increased knowledge. Confidence comprehending quality dashboards increased (13% versus 49%, P < .001). PGY-1 posttest responses were similar to those of 252 graduate controls for accessibility of hospital leaders, filing event reports, and quality dashboards. PGY-1 residents in the QI/PS curriculum reported more patient safety events than PGY-1 residents not exposed to the curriculum (0.39 events per trainee versus 0.10, P < .001). CONCLUSIONS: An interdepartmental curriculum was acceptable to residents and feasible across 3 specialties, and it was associated with increased event reporting by participating PGY-1 residents.

Surgeon-patient communication during awake procedures.

BACKGROUND: Surgeons are increasingly performing procedures on awake patients. Communication during such procedures is complex and underexplored in the literature. METHODS: Surgeons were recruited from the faculty of 2 hospitals to participate in an interview regarding their approaches to communication during awake procedures. Three researchers used the constant comparative method to transcribe, code, and review interviews until saturation was reached. RESULTS: Twenty-three surgeons described the advantages and disadvantages of awake procedures, their communication with the awake patient, their interactions with staff and with trainees, the environment of awake procedures, and how communication in this context is taught and learned. CONCLUSIONS: Surgeons recognized communication during awake procedures as important and reported varied strategies for ensuring patient comfort in this context. However, they also acknowledged challenges with multiparty communication during awake procedures, especially in balancing commitments to teaching with their duty to comfort the patient.

Implementing a resident acute care surgery service: Improving resident education and patient care.

BACKGROUND: To simulate the duties and responsibilities of an attending surgeon and allow senior residents more intraoperative and perioperative autonomy, our program created a new resident acute care surgery consult service. METHODS: We structured resident acute care surgery as a new admitting and inpatient consult service managed by chief and senior residents with attending supervision. When appropriate, the chief resident served as a teaching assistant in the operation. Outcomes were recorded prospectively and reviewed at weekly quality improvement conferences. The following information was collected: (1) teaching assistant case logs for senior residents preimplentation (n = 10) and postimplementation (n = 5) of the resident acute care surgery service; (2) data on the proportion of each case performed independently by residents; (3) resident evaluations of the resident acute care surgery versus other general operative services; (4) consult time for the first 12 months of the service (June 2014 to June 2015). RESULTS: During the first year after implementation, the number of total teaching assistant cases logged among graduating chief residents increased from a mean of 13.4 ± 13.0 (range 4-44) for preresident acute care surgery residents to 30.8 ± 8.8 (range 27-36) for postresident acute care surgery residents (P < .01). Of 323 operative cases, the residents performed an average of 82% of the case independently. There was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, P < .01 on a 6-point Likert scale) and complexity of cases (mean 5.35 vs 4.94, P < .01) on service evaluations of resident acute care surgery (n = 27) in comparison with other general operative services (n = 127). In addition, creation of a 1-team consult service resulted in a more streamlined consult process with average consult time of 22 minutes for operative consults and 25 minutes for nonoperative consults (range 5-90 minutes). CONCLUSION: The implementation of a resident acute care surgery service has increased resident autonomy, teaching assistant cases, and satisfaction with operative case variety, as well as the efficiency of operative consultation at our institution.

Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions.

BACKGROUND: Poor communication is a known contributor to disasters in aviation and medicine. Crew members are trained to raise concerns about superiors' plans, yet literature exploring surgical trainees' responses to analogous concerns is sparse. METHODS: Surgical residents were interviewed about approaches to concerns about supervisors' clinical decisions using a semistructured guide. Emerging themes were developed using the constant comparative method. RESULTS: Eighteen residents participated. They expressed a tension between conceding ultimate decision-making authority to supervisors and prioritizing obligations to the patient. Systemic (eg, departmental culture, resident autonomy), supervisor (eg, approachability), trainee (eg, knowledge), and clinical (eg, risk of harm, evidence quality) factors influenced the willingness to voice concerns. Most described verbalizing concerns in question form, whereas some reported expressing concerns directly. CONCLUSIONS: Several factors affect surgical trainees' management of concerns about supervisors' plans. No consistent method is used. A tailored curriculum addressing strategies to raise concerns appears warranted to optimize patient safety.

Dissociation of somatic growth, time of sexual maturity, and life expectancy by overexpression of an RGD-deficient IGFBP-2 variant in female transgenic mice.

Impaired growth is often associated with an extension of lifespan. However, the negative correlation between somatic growth and life expectancy is only true within, but not between, species. This can be observed because smaller species have, as a rule, a shorter lifespan than larger species. In insects and worms, reduced reproductive development and increased fat storage are associated with prolonged lifespan. However, in mammals the relationship between the dynamics of reproductive development, fat metabolism, growth rate, and lifespan are less clear. To address this point, female transgenic mice that were overexpressing similar levels of either intact (D-mice) or mutant insulin-like growth factor-binding protein-2 (IGFBP-2) lacking the Arg-Gly-Asp (RGD) motif (E- mice) were investigated. Both lines of transgenic mice exhibited a similar degree of growth impairment (-9% and -10%) in comparison with wild-type controls (C-mice). While in D-mice, sexual maturation was found to be delayed and life expectancy was significantly increased in comparison with C-mice, these parameters were unaltered in E-mice in spite of their reduced growth rate. These observations indicate that the RGD-domain has a major influence on the pleiotropic effects of IGFBP-2 and suggest that somatic growth and time of sexual maturity or somatic growth and life expectancy are less closely related than thought previously.

Gender-specific effects on food intake but no inhibition of age-related fat accretion in transgenic mice overexpressing human IGFBP-2 lacking the Cardin-Weintraub sequence motif.

IGFBP-2 affects growth and metabolism and is thought to impact on energy homeostasis and the accretion of body fat via its heparin binding domains (HBD). In order to assess the function of the HBD present in the linker domain (HBD1) we have generated transgenic mice overexpressing mutant human IGFBP-2 lacking the PKKLRP sequence and carrying a PNNLAP sequence instead. Transgenic mice expressed high amounts of human IGFBP-2, while endogenous IGFBP-2 or IGF-I serum concentrations were not affected. In both genders we performed a longitudinal analysis of growth and metabolism including at least 4 separate time points between the age of 10 and 52 weeks. Body composition was assessed by nuclear magnetic resonance (NMR) analysis. Food intake was recorded by an automated online-monitoring. We describe negative effects of mutant human IGFBP-2 on body weight, longitudinal growth and lean body mass (p < 0.05). Very clearly, negative effects of mutant IGFBP-2 were not observed for fat mass accretion throughout life. Instead, relative fat mass was increased in transgenic mice of both genders (p < 0.05). In male mice transgene expression significantly increased absolute mass of total body fat over all age groups (p < 0.05). Food intake was increased in female but decreased in male transgenic mice at an age of 11 weeks. Thus our study clearly provides gender- and time-specific effects of HBD1-deficient hIGFBP-2 (H1d-BP-2) on fat mass accretion and food intake. While our data are in principal agreement with current knowledge on the role of HB-domains for fat accretion we now may also speculate on a role of HBD1 for the control of eating behavior.

Recognizing clinical faculty's contributions in education.

OBJECTIVE: A faculty productivity profile system was designed to recognize faculty's contributions to administrative, educational, and research activities. It has long been recognized that clinical faculty receive little recognition or compensation for their efforts in education. Our surgery department previously had in place a recognition program for research achievements, but not for educational contributions. The new system was designed to recognize and reward all aspects of faculty contributions, including education. DESCRIPTION: The faculty productivity profile is a simple Excel document sent to each faculty member once a year. We piloted the program for the first time in 2001, recognizing faculty's contributions for the previous year. The pilot began with the formation of a committee whose first function was to identify all possible opportunities for faculty to participate as educators at our institution. This included giving lectures, participating in faculty development programs, serving as mentors, interviewing student or resident candidates, serving in administrative educational roles (e.g., clerkship or residency director), giving oral exams, or attending conferences and journal club. The committee then developed a point scale assigning each activity or contribution a value on a scale of 0-25. Each activity was then listed on the Excel form. Faculty were to fill in the number of times each activity was performed and this was multiplied by the points to obtain a weighted value. Point values for conferences were determined by percentage of conferences attended for a year (i.e., for grand rounds, those attending 0-49%, 50-75%, 75-90%, and more than 90% received 0, 20, 40, and 60 points, respectively). Points were also assigned for teaching awards and high scores on student and resident evaluations. After approval by the committee and the department chairman, the form was presented at a faculty meeting. Each faculty member then received a floppy disk with the form and was asked to complete the form and attach a supporting copy of his or her CV. The form required only input of numbers or a "yes" or "no." After submission, the clerkship coordinator input additional data from a database of conference attendance and student evaluations. Points were then calculated for each faculty member based upon his or her contributions and each activity's weighted value. A dinner was held to recognize outstanding faculty contributions. All faculty completing the form were invited and recognized and those with outstanding contributions received awards. DISCUSSION: Teaching medical students and residents is a rewarding experience; however, it requires significant time and effort. Faculty who feel their contributions are unrecognized may be more likely to burn out and less likely to continue contributing. We believe it is worthwhile to recognize faculty contributions in all areas, including education. Our pilot program had excellent participation due to the ease of using the form. We believe it has improved faculty morale and willingness to participate. We are continuing the program and plan to evaluate its impact on encouraging continued participation in teaching.

Questioning skills: the effect of wait time on accuracy of medical student responses to oral and written questions.

BACKGROUND: Pauses (wait time) after asking questions in pre-college classes result in improved discussion and answer accuracy. The authors hypothesized that this would extend to medical students. METHOD: Third-year surgery clerks were randomized to three-second or six-second wait times after questions asked of them during a scripted lecture. Students were randomized within each session to answer 21 scripted questions. Students also completed a post-lecture written examination. RESULTS: Correct responses ranged from 17% to 100% for oral and 22% to 100% for written questions. Answer accuracy could not be distinguished between three- and six-second wait times for oral or written questions. CONCLUSIONS: The benefit of increasing wait times from three to six seconds appears not to extend to medical students. This may represent evolution of learning or different learning modes in medical students. Alternatively, maximum benefit may be achieved in medical students with shorter wait times.

A formative midterm test increases accuracy of identifying students at risk of failing a third year surgery clerkship.

BACKGROUND: Providing midclerkship feedback to identify students at risk for failing is a Liaison Committee on Medical Education standard. Objective criteria for that feedback are critical. The investigators studied the value of a formative midterm (MT) test in identifying students at risk for failing a surgery clerkship. METHODS: A written midclerkship test, which did not contribute to the final grade, was administered (n = 155). The Bayesian specificity, sensitivity, and predictive values for clerkship failure of low MT score, low global clinical performance rating GCPR, and the combination of low MT and low GCPR were computed. RESULTS: Low MT as a predictor of clerkship failure was sensitive (1.0) but not specific (.35). Likewise, low GCPR was sensitive (1.0) but not specific (.31). The combination of low MT and GCPR, however, was both specific (1.0) and sensitive (.87). CONCLUSIONS: The addition of an MT test to clinical performance ratings can stratify students' risk for clerkship failure.

Complications of indwelling retrievable versus permanent inferior vena cava filters.

OBJECTIVE: Retrievable inferior vena cava (IVC) filters are appealing because they are designed for either retrieval or long-term use. However, the long-term safety of indwelling retrievable compared with permanent filters is largely unknown. This study was undertaken to compare complication rates and types associated with indwelling retrievable and permanent filters. METHODS: A retrospective review identified 1234 IVC filters (449 retrievable, 785 permanent) placed in 1225 patients from 2005 to 2010. Patients with retrievable filters removed electively were excluded, yielding 383 patients in whom retrievable filters were left in place. These patients with indwelling retrievable filters were compared with those with permanent filters with respect to demographics, comorbidities, survival, and complication rate and type. Differences in patient characteristics were tested with χ(2), Fisher exact, and Wilcox rank-sum tests. Logistic regression was used to identify predictors of complications. Because there were differences in the characteristics of the patients with indwelling retrievable filters and permanent filters, an additional propensity score analysis was performed yielding 319 patients in each group. RESULTS: Patients with indwelling retrievable filters were younger than those with permanent filters (mean age, 62 vs 75 years; P < .0001). Patients with indwelling retrievable filters had significantly more complications than those with permanent filters (9% vs 3.0%; P < .0001) after mean follow-up of 20 months (range, 0-86 months). Filter complications were categorized as thrombotic, device related, or systemic. While the most common complication type with both indwelling retrievable and permanent filters was thrombotic (4.4% vs 2.2%; P = NS), device-related complications were significantly more common with indwelling retrievable filters compared with permanent filters (3% vs 0.5%; P < .006). Propensity score analysis demonstrated that even in the matched groups, indwelling retrievable filters were associated with significantly more complications than permanent filters (9.1% vs 3.5%; P = .0035). CONCLUSIONS: Indwelling retrievable IVC filters were associated with significantly higher complication rates than permanent filters. Both thrombotic and device-related complications were more common with retrievable filters. Long-term use of retrievable filters should be avoided, especially considering the younger population in whom they are placed.

Surgeons managing conflict in the operating room: defining the educational need and identifying effective behaviors.

BACKGROUND: Developing an operating room conflict management educational program for surgeons requires a formal needs assessment and information about behaviors that represent effective conflict management. METHODS: Focus groups of circulating room nurses and surgeons were conducted at 5 participating centers. Participants responded to queries about conflict management training, conflict consequences, and effective conflict management behaviors. Transcripts of these sessions served as the data for this study. RESULTS: Educational preparation for conflict management was inadequate consisting of trial and error with observed behaviors. Conflict and conflict mismanagement had negative consequences for team members and team performance. Four behaviors emerge as representing effective ways for surgeons to manage conflict. CONCLUSIONS: There is a clear educational need for conflict management education. Target behaviors have now been identified that can provide the basis for a theoretically grounded and contextually adapted instruction and assessment of surgeon conflict management.

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict.

BACKGROUND: Prior research has shown that surgeons who effectively manage operating room conflict engage in a problem-solving stage devoted to modifying systems that contribute to team conflict. The purpose of this study was to clarify how systems contributed to operating room team conflict and clarify what surgeons do to modify them. METHODS: Focus groups of circulating nurses and surgeons were conducted at 5 academic medical centers. Narratives describing the contributions of systems to operating room conflict and behaviors used by surgeons to address those systems were analyzed using the constant comparative approach associated with a constructivist grounded theory approach. RESULTS: Operating room team conflict was affected by 4 systems-related factors: team features, procedural-specific staff training, equipment management systems, and the administrative leadership itself. Effective systems problem solving included advocating for change based on patient safety concerns. CONCLUSIONS: The results of this study provide clarity about how systems contribute to operating room conflict and what surgeons can do to effectively modify these systems. This information is foundational material for a conflict management educational program for surgeons.