Surgeon Incivility in the Preoperative Setting: A Multi-institutional Crossover Study on Anesthesiology Residents' Decision-Making.

BACKGROUND

Incivility in the perioperative setting is recognized as a threat to patient safety and workforce well-being. Anesthesiology residents are in a critical phase of developing professional judgment, making them potentially vulnerable to interpersonal dynamics. We sought to evaluate the impact of surgeon incivility on residents' decisions to either proceed with or postpone surgery in simulated cases characterized by clinical equipoise.

METHODS

We conducted a prospective, randomized, blinded, crossover study at two academic medical centers (Mount Sinai Health System and University of North Carolina) between September 2024 and April 2025. Participants were Postgraduate Year (PGY) 2 to 4 anesthesiology residents. Each resident completed two objective structured clinical examination (OSCE) scenarios-a medically complex case and an ethical dilemma-designed to be clinically ambiguous. Participants were randomized to interact with a standardized surgeon actor who displayed either civil (collaborative) or uncivil (rude, dismissive) behavior. Blinded attending anesthesiologists evaluated the residents' decision to proceed or postpone and rated their performance using behaviorally anchored rating scales (BARS).

RESULTS

After exclusions, 79 residents were analyzed in the logistic mixed-effects model. Residents exposed to the uncivil condition were significantly more likely to proceed with surgery than those in the civil condition (odds ratio = 2.25; 95% confidence interval [CI], 1.07-4.74; P = .03). There were no statistically significant differences in resident performance scores between civil and uncivil encounters across the domains of situational awareness (P = .50), communication (P = .09), or decision-making (P = .50). Apart from relationship status, demographic variables and personality traits did not significantly influence the primary outcome. Interclass correlation coefficients demonstrated moderate reliability among attending BARS performance ratings.

CONCLUSIONS

Surgeon incivility significantly influenced anesthesiology residents to proceed with surgery in clinically ambiguous situations, overriding the tendency to postpone as observed in civil encounters. This shift occurred despite preserved performance scores, suggesting that incivility exerts a coercive influence on clinical judgment. Future studies are needed to characterize the effect of incivility across broader cohorts and to evaluate the efficacy of specific interventions intended to mitigate its impact.