Role-modelling in the operating room: medical student observations of exemplary behaviour

Abstract

Medical Education 2011: 45: 946–957

CONTEXT  Training future doctors to develop an appropriate professional persona is an important goal of medical student education and residency training. Most medical education research paradigms on professionalism have focused largely on lapses (e.g. yelling as an example of communication failure) and tend to emphasise behaviour that should be avoided. The assumption is that, if left unchecked, students will see these negative behaviours exhibited by their role models and possibly emulate them, allowing the potential reinforcement of the inappropriate behaviours.

OBJECTIVES  Identifying and characterising exemplary, or positive, behaviours can be similarly valuable to both medical students and residents as tangible examples of behaviours to strive towards. The goal of the present research was to determine and thematically define the exemplary professional actions that medical students observe in the intense and patient-focused environment of the operating room (OR).

METHODS  Using qualitative methodology of content analysis and theme identification, we systematically documented the type of exemplary professional behaviours reported by medical students (n = 263) when observing health care teams on an anaesthesia rotation in the OR.

RESULTS  The analysis generated a taxonomy of exemplary OR behaviour that included six overarching themes (e.g. teamwork), 15 sub-themes (e.g. collegial) and numerous exemplars (e.g. showed mutual respect). These themes and sub-themes were then conceptually ‘matched’– through the use of antonyms – to complement an existing framework focused on medical student reports of professional lapses witnessed during medical school.

CONCLUSIONS  Year 3 medical students in the USA reported observing very positive, exemplary health care provider interactions that were diverse in focus. Themes were identified regarding the OR team members’ interactions with patients (calm, communication, comforting), with one another (teamwork, respect) and with the medical students (teaching). This classification of exemplary OR behaviour contributes to our understanding of how professional behaviour is viewed and potentially emulated by medical students on surgical rotations.

Introduction

The process by which doctors acquire the knowledge and skills to practise medicine is an ongoing research interest. It is one that is well represented in the medical education research literature,¹ as well as in the field of expertise development.² The means by which doctors learn the behaviours that define being a professional, however, have been more challenging to conceptualise, evaluate and implement.^3–6

Medical students are expected to apply medical knowledge, learn hands-on procedural skills and acquire professional behaviour through an ‘apprenticeship model’ by shadowing and observing doctor role models throughout their medical school education. A unique setting for observing and training medical professionals is the operating room (OR). Non-technical skills, such as good communication skills, are important assets for surgeons and other OR team members because these skills help the team to avoid errors and to function efficiently.⁷ Conflict in the OR has been shown to adversely impact patient care.⁸ Moreover, in this environment, the elements of appropriate professional behaviour can often be marred by the fact that the time available for decision making is compressed, especially in trauma situations. Nevertheless, these OR interactions are considered as ‘learning moments’. Indeed, such informal role-modelling scenarios – in which OR team members function as role models with or without their comprehension of this fact – occur constantly.⁹

Workshops and seminars on appropriate professional behaviours are held regularly for medical students in order to supplement observational learning and training. However, in clinical settings, students often report observing behaviours by doctors that are not appropriate or that contradict behaviours that are emphasised during class.¹⁰ As a result, medical students may feel appropriate professional behaviour is unimportant, despite efforts to the contrary.¹¹

Background

Most research studies into professional behaviour in the past have focused largely on professional lapses (e.g. communication failure) and the development of formal conceptual frameworks for unprofessional behaviour in medicine.^6,12 These studies have been based on the concept that ‘it is necessary to understand the professional challenges and dilemmas [the students] perceive in the clinical setting’⁵ in order to support their development of professionalism. A coding system for lapses in professional behaviour has been developed to identify action-oriented and contextual rather than theoretical situations.⁶ In this system, lapses in professional behaviour are well characterised; they include communication violations, role resistance, objectification of patients, ignoring patients, treating patients as vehicles for learning, denying accountability, subjecting patients to crossfire between members of the health care team and causing physical harm.⁶

More recently, medical education researchers have attempted to shed light on the effects of emphasising exemplary professional behaviour over professional lapses by observing and documenting expert behaviour in the field² and by deliberate role-modelling.^13,14 Medical professionalism as defined by the American Board of Internal Medicine¹⁵ includes altruism, honesty, respect for others and accountability, and applies to patient interactions as well as to interactions with fellow staff. Studies focused on exemplary professional behaviour¹⁶ have emphasised that it is important that doctors in training can recognise such behaviour if they are to emulate it.^17,18

Exemplary professional behaviour has been documented in recent studies¹⁹ by analysing notable incidents of professional behaviours during patient interactions. In another approach, Maker and Donnelly²⁰ noted that junior surgical residents have a high regard for senior residents who show good professional behaviour. Other studies have defined good professional behaviour through reports by senior residents, medical students, faculty members and other staff.²¹ These studies show that medical students, interns and residents are able to report and reflect on their own exemplary behaviour, as well as on that of others.

Fewer studies have systematically defined the construct of exemplary professional behaviour. Such work is necessary, however, if we are to build it into the curriculum and develop instruments with which to evaluate it.^22,23 Moreover, identifying and characterising exemplary behaviours can be valuable to both medical students and residents because they often do not accurately perceive their own behaviour as appropriate or inappropriate.^24,25 This inability to self-assess is surprisingly common among young trainees.²⁶ In addition, junior or novice team members often mimic the behavioural styles of their senior counterparts during high-tension situations in the OR.⁹ Emphasising exemplary behaviours during these situations should foster professionalism and train better doctors.

Rationale

Using the perspective of medical students as a reference point, we extended this line of research to observe doctor behaviour in the OR. Anecdotal reports indicate that the OR environment can be harsh, demeaning and impersonal. Thus, exemplary professional behaviour is thought to be hard to find here. The goals of this study were: (i) to determine the type of exemplary professional behaviour medical students were observing in the OR, and (ii) to thematically document their analysis of the observed exemplary OR behaviours. These goals were achieved through qualitative methodologies that will be discussed in the next section. Documenting and analysing the various types of exemplary behaviour observed in the OR allows us to help students develop and apply appropriate professional behaviour throughout their careers. Our study shows that medical students see a wide range of exemplary professional behaviour demonstrated across the range of individuals who make up an OR team. The resulting framework is complementary to other models of medical students’ views of professionalism and adds to our understanding of how implicit learning of exemplary (i.e. good) behaviour occurs through informal role-modelling.

Methods

Setting

Year 3 medical students in groups of 15 were required to participate in a 1-week clerkship in anaesthesia in the OR at Columbia University’s College of Physicians and Surgeons in New York City. They were assigned to observe OR procedures and to shadow the OR anaesthesia team directly. Each anaesthesia team included an attending physician and a resident or nurse anaesthetist. Indirectly, the students also observed the professional behaviours of the surgical team and other OR team members. The surgical team included an attending surgeon and various resident doctors or fellows. The remaining members of the OR team included nurses and other supporting members of the patient care team.

Participants, materials and procedures

While on this 1-week anaesthesia clerkship, Year 3 medical students from two consecutive medical student year groups (n = 268, 97% of all possible students) were asked to document two OR team interactions that they observed and judged to be notable. We asked that one interaction be categorised as exemplary (i.e. good) and one as a lapse (i.e. bad) in professional behaviour. (Further details on how these were categorised are given below.) The clerkship director informed students that this was part of their professional development training and asked that all materials be submitted anonymously. The investigators subsequently obtained institutional review board approval to analyse the students’ responses.

On the first day of the clerkship the director distributed an interaction form to the students (Table 1, column 1 for contents). To simplify the terminology of ‘exemplary behaviour’ or ‘professional lapse’, we chose to have the medical students use the heuristic of ‘good’ as a proxy for exemplary behaviour and ‘bad’ as a proxy for professional lapses. The students were asked to record the position or rank of the people involved in the interaction (e.g. attending anaesthesiologist, surgical resident, nurse, family member), but not their names. Half-way through the 1-week clerkship, students met with the course director as a group to submit the forms and discuss what they had seen.

Table 1.   Examples of medical student reports of exemplary behaviour and lapses in professionalism in interactions between health care providers and their patient(s) (provider–patient) and among health care providers (provider–provider).

PIF question*	Exemplary (Good)	Lapse (Bad)
{} denotes presence, but not involvement PIF = personnel interaction form; ASU = ambulatory surgery unit; OR = operating room; LP = lumbar puncture
Health care provider–patient interaction
Who was involved?	Anaesthesia resident Patient	Attending anaesthesiologist Patient
Where?	Preoperative unit (ASU)	OR
Interaction description	‘Nervous patient, scared about surgery, had list of questions and concerns for “the doctors”; anaesthesia resident calmed the patient, answered questions, explained the anaesthesia in a detailed but comforting manner, and never appeared rushed’	‘The attending was impatient with the patient as he attempted to position the patient for an LP. Patient never was given a clear description of how to position himself and MD did not realise that the patient was unclear on what he was supposed to do. MD told patient to “arch” back when he meant to “round” back’
What was Good or Bad about the interaction?	‘Resident gained the patient’s trust and allayed his fears by being patient’	‘The attending [physician] was not in tune with the patient’
What would you do differently or emulate?	‘Emulate his patience, willingness to spend time with patient’	‘Verify the patient’s understanding of what you’re asking him to do rather than repeating the directions when the patient is not following directions’
Health care provider–provider interaction
Who was involved?	Attending surgeon Anaesthesia resident	Attending anaesthesiologist Attending surgeon {Patient}
Where?	OR	Other
Interaction description	‘In the paediatric emergency room a quick procedure was being done. The surgeon came in and worked quickly but thanked the anaesthesiologists upon leaving. The atmosphere was very friendly and congenial and very pleasant’	‘Patient was on the cystoscopy suite table, awake, feet in stirrups, had gotten spinal anaesthesia. Surgeon walks in and anaesthesiologist said: ‘If you’re going to be late, can you tell me so I don’t have the patient waiting on the table?” Surgeon whirls around and starts yelling and swearing at the anaesthesiologist: “You can’t tell me when to be here! I’ve waited for you before!” etc.’
What was Good or Bad about the interaction?	‘Everyone was very respectful to one another’	‘Arguing in front of the patient, not privately; swearing; not apologising for behaviour’
What would you do differently or emulate?	‘Acknowledge the other people in the room and thank them’	‘No yelling/swearing. No arguing in front of patient, especially if she’s in a vulnerable position; apologise if lose control’

Examples of student reports of both exemplary behaviours and lapses are located in Table 1. Over a 2-year period, we collected the two interaction forms (good and bad) from all but 16 of the 268 participants (who submitted only one ‘good’ form). In addition, 33 forms were removed from analysis because they were illegible or contained incomplete information. Of the remaining 487 observed interactions, 203 (42%) focused on doctors and 118 (24%) focused on residents (Fig. 1). The remaining 166 forms (34%) focused on the team as a whole, nurses, or other health care team members present in the OR. Of the 268 ‘good’ forms submitted, eight reports included content we were unable to code and therefore they were removed from analysis.

Figure 1.  Distribution (in %) of the type of interaction (‘exemplary’ versus ‘lapse of professionalism’) of the original 487 interactions observed by medical students, grouped by health care team role

Analysis

We wanted to highlight the exemplary behaviours that students chose to report. We therefore devised our own system for coding exemplary OR behaviour using a modified grounded theory approach.^6,27 We then took the taxonomy of exemplary OR behaviour that emerged and compared it with a transformation of the themes in Ginsburg et al.’s⁶ framework for lapses in professional behaviour. Thus, we took the antonym of each theme. For example, the Ginsburg et al.⁶ theme of ‘communication violation’ as a lapse was transformed into ‘communication excellence’ as exemplary professional behaviour in the OR. Our independently derived taxonomy of exemplary OR behaviour themes and sub-themes was then ‘matched’, where possible, to this transformation.

What follows is a description of our iterative process of coming to consensus on the taxonomy of exemplary OR behaviour from the perspective of Year 3 medical students on an anaesthesia clerkship. Also included is a comparison of how well our results fit with existing models of professional OR behaviour in the medical education literature that use qualitative methodology similar to that of Ginsburg et al.⁶

Results

Year 3 medical students’ first-hand reports of exemplary behaviour in the OR are summarised in taxonomic form (i.e. a hierarchical classification structure) in Table 2. In accordance with previous applications of grounded theory,^6,27 this taxonomy represents a qualitative analysis of students’ reported observations. What follows is a synthesis of the language used by the students to describe instances of exemplary behaviour. The main themes that emerged from our analysis are shown in Table 2 in order of frequency of appearance (out of a final total of 260). They include: Calm (n = 73); Teamwork (n = 70); Teaching (n = 45); Patient Communication (n = 29); Comforting (n = 22), and Respect (n = 21).

Table 2.   Taxonomy of exemplary operating room (OR) behaviour as reported by Year 3 medical students on an anaesthesia clerkship who were shadowing residents and attending physicians in the OR

Major theme (n = 260)	Sub-themes (%)	Observed exemplary behaviours
Calm (n = 73)	Calmed patient (77%)	Allayed fears; calming talk; put at ease; reassuring; relaxed; relieved anxiety; soothing; supportive; took time; treated kindly; used humour to relieve anxiety
	Remaining calm professionally (15%)	Appropriate handling of a difficult situation; calm under fire; kept cool; maintained composure; stayed calm
Teamwork (n = 70)	Cooperative team members (29%)	Deferred to expertise; visibly cooperative; worked together
	Communicative (26%)	Aware of actions and apologetic; complimentary; considerate of others’ responsibilities; explaining; good communication in adversity; good coordination; friendly greeting; kept informed and let others know of potential problems; reassuring
	Collegial (19%)	Didn’t yell at one another when under duress; good camaraderie; good rapport; humour as team stress reducer; offered help; pleasant; relaxed environment; showed mutual respect; spoke well of others
	Cooperative in providing patient care (14%)	Acknowledging limitations; collectively explained and reassured; supported other provider(s) in front of patient; team worked together in reassuring patient
Teaching (n = 45)	Role (51%)	Focused on learning and good teaching; constructive advice; ‘pimping’, teasing, and questioning in a friendly way; willing, took time and made opportunity to teach; considerate within supervision; role-modelling of self-control; asked probing questions; developed a shared understanding
	Inclusive (22%)	Invited; shared sense of belonging; supportive of medical student involvement; welcomed medical student
	Supportive (11%)	Encouraging; supportive of resident
Patient communication (n = 29)	Explained to patient (93%)	Explained plan; gave appropriate information; listened to patient while in process of explaining
	Prioritised patient (7%)	Patient given sense of dignity or control; prioritised concerns
Comfort (n = 22)	Comforted patient (100%)	Compassionate; ensured comfort; extra effort to make patient feel better; proactive in comforting and reassuring; warm interaction
Respect (n = 21)	To team (29%)	Thanked all; took time to explain situation to team
	To patient (52%)	Being supportive; considerate; empathy; kind to patient; sincerely demonstrated humanity; sympathy and compassion
	Courteous (19%)	Asked nicely; courteous; resident apologised to nurse

Calm

Seventy-three comments around the theme of calm were identified. Two sub-themes emerged, including calming patients and individual providers remaining calm when facing adversity (Table 2). Of these 73 reports, 77% were identified as belonging to the calming patients theme; the majority referred primarily to anaesthesia and surgical residents’ interactions with patients in which they were ‘reassuring’ and ‘allayed fears’. For example:

‘The patient and her family were together waiting for an OR procedure to begin that was now 4 hours late. They were getting anxious and agitated because they did not know what was going on. Dr X [the surgical resident), after becoming aware of the situation, calmed them down by giving information and occasionally going back to give updates. [I saw] that the surgical resident recognised the anxiety and went out of his way to help. I would hope to show the same awareness, caring and compassion towards patients, especially when they have been kept waiting for an operation without anyone informing them of developments.’

Medical students’ reports of calm behaviours also referred to members of the OR team remaining calm in difficult or potentially volatile situations. For example:

‘Pre-surgical evaluation suggested that the next [OR patient] was a straightforward intubation candidate. But when the time came to begin the procedure, the case became complicated: two anaesthesia attendings and a senior resident were needed, as was fibre-optic technology; also, the patient had to be mildly awake to aid the intubation. As the difficulty of the situation increased, the general level of stress/anxiety in the OR escalated. Yet even though the attending surgeon was clearly getting agitated, the senior resident and attending anaesthesiologist never once lost composure. [To me] the situation highlighted the importance of remaining composed, as well as confident in one’s ability in times when difficulty increases.’

Teamwork

Of the 70 observations coded within the theme of teamwork (Table 2), four general sub-themes emerged with roughly equal distribution across categories: being communicative (26%); being collegial (19%); being a cooperative team member (29%), and team cooperation in providing patient care (14%).

Descriptions of communicative incidents during teamwork settings were commonly reported by the medical students. These referred to attending physicians who ‘explained’ what they were doing to one another, the attending anaesthesiologist who ‘let other team members know of potential problems’ or the resident who demonstrated ‘good communication in adversity’.

In the second sub-theme, collegial, teamwork descriptions such as that of the whole OR team as ‘warm and friendly’ or displaying ‘good camaraderie’ were common. Often, medical students’ descriptions referred to teaching, yet, in these cases, the most commonly noted aspect was the atmosphere that was established (‘relaxed/good environment’, ‘didn’t yell’) in addition to the teaching itself.

The third sub-theme, being a cooperative team member, reflected the focus of medical students on an individual OR team member. Examples included an anaesthesia or surgery attending physician who was ‘working together’ with others or being ‘visibly cooperative’. Similar reports were common for interactions between the attending anaesthesiologist and resident. For example:

‘The attending surgeon maintained open communication (two-way) with the anaesthesiology resident throughout the procedure. Each anticipated the needs of the other in advance, and this continued afterwards as they spoke about upcoming patients. [I saw] an ideal surgeon–anaesthesiologist relationship: the tone was cooperative and the anaesthesiology resident was treated as an equal colleague (in contrast to other interactions I’ve witnessed).’

For the fourth sub-theme, team cooperation in patient care, the themes were coded as distinct from the calm category within the taxonomy because the action represented a group or team effort rather than that of an individual actor such as the attending anaesthesiologist. Team members who were seen together ‘explaining’, ‘reassuring’ or ‘calming’ the patient were common in the medical students’ reports.

Teaching

Of the 45 instances coded under the heading of teaching (Table 2), three sub-themes emerged (role, inclusive, supportive). The first theme referred to attending physicians and their role as teachers while in the OR. These observations focused on a demonstrated ‘willingness to take time’ to teach, or those who ‘were considerate within supervision [of residents]’. For example:

‘An attending anaesthesiologist was waiting for the start of the next case and he took the time to teach me and the anaesthesia resident. He tailored his talk to our varying levels of experience and made pertinent important points for a medical student to understand from an anaesthesia rotation and points relevant to a resident. [I experienced] an attending [physician] who was willing to teach and [who] also considered the medical student’s and the resident’s point[s] of view before teaching.’

The second theme of exemplary behaviour in teaching referred to medical students’ experiences of a feeling of inclusion in OR teaching situations. Exemplary behaviour to them meant feeling ‘welcomed’ and ‘supported’. Moreover, across the 10 reports coded in this category, the ‘shared sense of belonging’ involved some or all OR team members (nurses, attending and resident anaesthesiologists, attending surgeons) being ‘supportive’ and ‘encouraging’ of the learner. For example:

‘I entered the OR as things were getting started and was welcomed by the resident and attending. The resident let me do a few things immediately, taught well, and included me in everything he was doing. [I felt that] the resident and attending seemed to remember what it was like being a student; they helped, taught, showed, etc.; they were pleasant and non-intimidating.’

The third sub-theme involved a feeling of being supportive or supported within the teaching situation, such as when the anaesthesia attending physician is ‘positive’ and ‘encouraging’ while engaged in teaching the anaesthesia resident:

‘[The] resident had difficulty placing [the] arterial line. [He] called [the] attending to do it, but when the attending came, he said that he was sure that the resident could do it. He waited and gave constructive comments while the resident tried again and placed the line successfully. He did not yell at the resident. Instead, the attending was supportive and patient.’

Patient communication

Twenty-nine instances in which medical students reported seeing exemplary behaviour among the OR team were coded into two sub-themes referring to: (i) when health care providers explained something to the patient, and (ii) when providers prioritised the patient (Table 2). The first theme primarily involved the anaesthesiology residents with a patient who was being prepared for the OR. For example:

‘The anaesthesia resident was unable to get an i.v. into the patient’s preferred arm and caused some bruising in the process. The resident explained why he was unable to get [the] i.v. in (due to a venous valve). This [pre-emptively] put [the] patient at ease about the resident’s competence. [I saw that] instructing patients about what you are doing can increase the confidence patients have in your abilities to provide them with excellent care.’

Other descriptors that emerged within this theme involved residents who ‘gave appropriate information’ to the patient or ‘listened to the patient while in the process of explaining’. In addition, some medical student reports conveyed the sense that in performing the tasks necessary to prepare the patient for the OR, the anaesthesia attending physician or resident ‘prioritised the patient’s concerns’ and even ‘gave the patient a sense of dignity or control’. For example:

‘The doctor made a point to have the patient hold her own facemask. The attending said [to me] that since the patient is having so many things done to her, the least we can do to give her some sense of dignity/control is to have her help out and do as much as she can (i.e. hold her own facemask). [To emulate this] I will also try to find little things (that may seem insignificant) that patients can do themselves.’

Comforting, respect and empathy

The remaining three themes appear separately in Table 2, but are described together here for efficiency. The theme of comforting largely revolved around members of the OR team who ‘took extra effort to make sure the patient felt better’ in some way. The sense of ‘extra effort’ is what separated a report from the calm theme (Table 2) because the patient in question was not expressing any overt or disabling fear, anxiety, etc. Within this context of comforting, the medical students noticed attending physicians, residents and nurses offering steady ‘reassurance’ or ‘warmth’. For example:

‘A very obese patient (+500 pounds) was having gastric bypass surgery with only local sedation [i.e. he was awake and aware]. Everyone involved in his surgery helped [to] reassure him and [to] make a difficult situation a little more bearable. The patient was continuously communicated with in a compassionate manner. The procedure could have been much more difficult had this communication not occurred. [I learned to] always remember communication with the patient and anticipate concerns, and be prepared with honest and reassuring answers.’

Regarding the theme of respect, we determined it to be distinct from the theme of teamwork in that it refers more to an individual’s acknowledgement of other OR roles. In the 15 instances coded in this theme, three sub-themes emerged ([respect] to team, [respect] to patient, courteous) with relatively equal frequency. The first indicates a kind of respect shown to the OR team whereby the attending surgeon – out of respect for each team member’s involvement in what was to come –‘explained to the team the [developing] situation’ in order to help them with their responsibilities. Additionally, medical students reported seeing the attending surgeon express ‘gratitude’ to the OR team. The second sub-theme of respect referred to the perspective of the patient and related to occasions when attending physicians or residents were ‘considerate’, ‘empathetic’, ‘sincere’ or ‘supportive’. For example:

‘The anaesthesia resident, regardless of how busy he was, always put the patients first, and always strived to make them comfortable. He knew the patients hated NG [nasogastric] tubes and tried to get rid of them as soon as they were not needed, and this really made a difference in the patient’s well-being. [In terms of what to emulate] there were a lot of things I learned from him, like never to be judgemental about a patient, never be condescending to patients, and to always think about their comfort.’

The third sub-theme related to being courteous through respectful behaviour such as when an anaesthesia resident ‘apologised’ to a nurse on the OR team:

‘The anaesthesia resident accidentally forgot to check with the scrub nurse before bringing in the patient. The nurse pointed this out and the resident apologised. As this transpired, respect and understanding predominated. They were respectful and kind to each other despite a potentially uncomfortable circumstance (i.e. making a mistake). [I know that] there are times when people are unkind and rude when someone makes a single mistake. I don’t want to be like that. These people were not like that.’

Integration of exemplary or behaviour taxonomy

Table 3 represents the following: (i) Ginsburg et al.’s⁶ original coding of lapses in professional behaviour; (ii) the transformation (via the antonym) of the lapse language into an exemplary OR behaviour framework, and (iii) appearances of themes and sub-themes from the taxonomy of exemplary OR behaviour wherever we determined there was a ‘match’. This determination was based on the consensus of the present authors. As Table 3 shows, the majority of (sub-)themes could be placed within the existing framework. (The one exception concerned the exemplary OR behaviour of teaching, which will be discussed further in the next section.)

Table 3.   Transformation of Ginsburg et al.’s conceptual framework of lapses in professional behavior⁶ to a framework for exemplary behaviour using the antonym of each term. When the framework for exemplary behaviour had been established, a ‘matching’ procedure paired themes and sub-themes from the taxonomy of exemplary operating room behaviour in Table 2

HCP = health care provider
Lapses in professional behaviour →(Ginsburg et al.^6)	Exemplary behaviour ↔(Transformation of Ginsburg et al.^6)	Taxonomy of exemplary OR behaviour MATCH
Communications violations  To patients  About patients  To other HCPs  About other HCPs	Good communication  With patients  With other HCPs	Teamwork  Cooperative team member  Communicative  Collegial  Cooperative in providing patient care Patient communication  Explained to patient
Role resistance	Role adaptation	Respect  To team  To patient  Courteous
Objectification of patients Ignoring patients Patients as vehicles for learning	Humanisation of patients	Calm  Calmed patient Patient communication  Explained to patient
Accountability  To other HCPs  To patients	Accountability	Patient communication  Prioritised patient
Physical harm	Protection of patients	Comforted patients
Crossfire	Removal from crossfire	Calm  Remained calm professionally
–	–	Teaching  Role  Inclusive  Supportive

Discussion

Our results demonstrate that Year 3 medical students on an anaesthesia clerkship rotation in the OR were able to witness very good health care provider interactions that were diverse in focus. They were able to include in their reports interactions among patients, attending physicians, residents, medical students, nurses and the OR team as a whole. The themes identified referred to OR team members interacting with patients (calm, communication, comforting), with one another (teamwork, respect) and with the medical students (teaching). We were also able to show that these accounts are compatible with an existing framework of professional behaviour that was similarly derived from medical students through qualitative methodology (Table 3).

It is important to note that the students were not shy about making comments. They explicitly stated what they saw and why they thought it was exemplary behaviour. The comments did not mention the theories of professionalism nor its language (i.e. altruism, accountability, honesty, respect for others). Instead, student reports represented exemplary OR behaviour as a series of actions by the doctors involved.

The students saw the acts of calming and comforting patients, staying calm in difficult circumstances, and communicating well with patients as demonstrations of good behaviour compatible with their perception of the way a doctor should behave. Although the OR staff may have performed a particular operation many times, the procedure usually represented a first and very personal moment for the patient. From the reports offered in this study, we see that medical students appreciated the staff’s handling of this.

Teamwork among different services was seen as important in smoothing the OR experience for all involved. It is important that the medical students were able to identify teamwork as indicative of exemplary OR behaviour because it has future value as they move through medical school and into residency. For example, the hospital accrediting agency in the USA, The Joint Commission (TJC), has noted that patient safety is at risk from the disruptive behaviour of health care professionals and lack of teamwork.²⁸ Because the medical students in this study witnessed this team-based behaviour from a positive, exemplary perspective, it may provide them with a more well-rounded understanding that smooth working teams are a critical element of patient care.

Respect for others included the understanding of patient sensibilities, but was noted more often in the respect demonstrated by health care professionals for one another. Students were able to understand that no single person was responsible for the good outcome of an operation. The medical students were aware that everyone involved had a role to play in the procedure and should be respected and appreciated for what they do.

Interestingly, we found that explicit teaching was a frequent characteristic of the exemplary behaviour noted by students. Because these observations were drawn from the perspective of students, this may not be unusual; today’s medical students pay a lot of money for their education and expect to have a steady stream of teaching and learning moments. The frequent mention of teaching in this study suggests that explicit teaching may not happen as often as students would like.

The fact that moments of overt, explicit teaching were so notable for many of the medical students creates a conundrum for the mainstay of clerkship and residency education, namely: implicit teaching through role-modelling. Role-modelling is common in the medical environment and can be a powerful tool for learning. For example, when Park et al.²⁹ interviewed surgical faculty staff and residents and asked them how they had learned professionalism, ‘learning by example’ was the most common method mentioned. Because much role-modelling is informal, it is important that medical students are made more aware that overt, didactic teaching is not the norm. In addition, teachers of medical students (in this case, the OR team) also need to be aware that, because of the implicit learning context of the OR, every one of their actions represents a ‘teaching moment’ during which some impressionable person may be ‘learning’.

To summarise, the resulting taxonomy of exemplary OR behaviour themes and sub-themes was ‘matched’ to that of an existing framework focused on medical student reports of general lapses of professionalism in medicine. As in the work on lapses in professional behaviour, it is important to note that the taxonomy represents medical student opinions of exemplary professional behaviour in the OR, which may only be an approximation of what would traditionally be defined as ‘professionalism’. Instead, our intent was to have medical students concentrate on identifying exemplary behaviours as they perceived them through the lens of the fast-paced, yet focused, environment of the OR. This allows for a more complete analysis of how professionalism is viewed and potentially emulated by medical students.

Implications

With reference to the focus on how to avoid professional lapses (e.g. ‘Don’t yell’), this study indicates that medical students do also see doctoring at its best and witness behaviour in which the solicitous care of the patient is placed first and foremost in the actions of practitioners. For the medical students, the relatively immediate discussions of these personal observations with faculty staff helped to reinforce the sense that these exemplary behaviours noted were worth emulating. Making this information known to the teachers of students may help in several ways. Firstly, it can show teachers that their exemplary behaviour is noted and appreciated. Secondly, this behaviour may then be reinforced and continued, to the betterment of patient care and the training of future doctors. Thirdly, by laying out a taxonomy of exemplary OR behaviour, we may be able to demonstrate to students as well as to faculty staff the type of behaviour they should aim for, rather than simply focusing on avoiding the classic lapses in professional behaviour.

Limitations

Our study is limited because our sample involved only two year groups of medical students and their experiences at a single large, urban institution. It is also limited because it was conducted within only the anaesthesia rotation, which lasts only 1 week, whereas other rotations in the OR (such as surgery) are longer and may offer opportunities for more extended observation and the formation of a different perspective over time. As has been suggested in the context of self-assessment, at least eight encounters with the same individual are necessary to give reliable information and avoid memory bias.²⁶

A further limitation is that students may have been somehow biased in their reporting because they were actually on an anaesthesia rotation and shared their experiences with the anaesthesia clerkship director directly. Yet, as the examples in Table 1 show, the patterns of perceived professional lapses displayed by attending physicians in particular seem to suggest otherwise; our medical students were not apprehensive about discussing attending physicians – in either exemplary terms or with regard to perceived professional lapses – with their anaesthesia clerkship director.

Finally, did explicit learning take place? This question is beyond the reach of the data we collected; however, each of the medical students’ observations included a statement about what the student perceived he or she had learned from the interaction and thus we can infer that teaching and learning occurred from the exercise of observations. The wish to emulate the observed behaviour was noted multiple times. Although this may not represent proof that learning occurred, it does at least indicate the potential that the observed exemplary behaviours will be remembered and practised.

Conclusions

In this study, we broadly documented the type of exemplary professional behaviours witnessed by medical students when observing their role models in the OR. This information can be used to better target how to train future medical students in exemplary behaviour in the OR. It can also be used to show to the OR team that their everyday behaviour is continuously monitored and is perceived as appropriate or inappropriate. Although lapses in professional behaviour must remain under focus for a number of reasons, including patient safety, we believe that making explicit exemplary OR behaviour contributes towards bridging the gap between classroom idealism and clinical reality in medical student professionalism education. What we show here through the lens of medical students’ observations in the OR is that there is a lot of ‘good’ going on too.

Contributors:  SEC conceptualised the study and research design, collected data, and collaborated on data analysis and interpretation, and the drafting of the article. CIC was responsible for data management and contributed to the interpretation of data, background research and the preparation of the manuscript. MJG oversaw the methodological process of the study and the management, analysis and interpretation of data, and contributed to the preparation of the manuscript. All authors collaborated on the critical revision of the manuscript and approved the final version for publication.

Acknowledgements:  the authors acknowledge Hilary Schmidt for collaborating on the conceptualising of this study, Boyd Richards for comments on an earlier draft, Leslie Wright and Gingi Pica for data preparation and analysis, and the editing of earlier drafts, and two anonymous reviewers for their helpful comments. Mark Graham is now at Yale University in New Haven, Connecticut, USA.

Funding:  none.

Conflicts of interest:  none.

Ethical approval:  this study was approved and deemed exempt from full ethical review by the Institutional Review Board of Columbia University Medical Center.