Surgical teams are more cooperative when women outnumber men in the operating room.

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Yelling, cursing less likely to break out in operating rooms when female surgeons are present

In 2015, a surgeon at a teaching hospital in Georgia—exasperated with his surgical team—shouted, “Am I not speaking clearly?! I’m going to have to start yelling!” Later, he slammed his headlamp to the floor and stormed out of the operating room. His team, which hadn’t yet finished the surgical procedure, was left stunned.

Conflicts like this flare up on occasion in operating rooms, where teams of skilled professionals work together in high-pressure environments. What made this conflict unusual was that an anthropologist—Laura Jones of Emory University in Atlanta—was in the room, carefully taking notes.

Her observations—which, all told, logged the nature of 6348 interactions during 200 operations—uncovered a surprising source of conflict in operating rooms: the gender balance of the surgical team. Conflict was most likely when male surgeons worked with male-dominated surgical teams, Jones and colleagues report today in the Proceedings of the National Academy of Sciences. Operations went more smoothly, with less yelling and other forms of conflict, when the surgeon was female or when male surgeons were surrounded by mostly women.

“It’s just absolutely fascinating,” says Joyce Wahr, an anesthesiologist at the University of Minnesota in Minneapolis who has studied patient safety but wasn’t involved in the new research. “I don’t think any of us have thought of it in that way. We just generally thought that certain people were jerks.”

Researchers have studied conflict in operating rooms, but they’ve mostly used surveys and interviews, not direct observations of interactions as they happen. The idea for the latest study was hatched when an anesthesiologist read a book about chimpanzees and their struggle for power over one another, which biologists study by logging different kinds of behavior. He told Frans de Waal, the book’s author and a primatologist at Emory University, that “the same observations could be made in the operating room.”

De Waal was stunned that no one had made those sorts of observations before. “It’s the most basic primatology you can imagine,” he says. “But it’s very illuminating.” So de Waal, Jones, and colleagues developed a classification system to describe different kinds of operating room behaviors, ranging from cooperative (teaching, chitchat) to confrontational (cursing, yelling).

“The vast majority of what happens in the operating room is not technical communication,” de Waal says. “It’s gossiping and joking and exchanging information. … All sorts of things happen there—flirting, dancing.”

Jones used the classification system to log operating room behaviors in Georgia teaching hospitals from 2014 to 2016, noting interactions between surgeons, residents, anesthesiologists, and nurses. Then, she and her colleagues zeroed in on behaviors that fell into two categories: cooperative (59% of interactions) and conflict-inducing (3%).

Her observations revealed that the most congenial operating rooms were made up of mostly women. Cooperative behaviors predominated—making up more than 60% of interactions—when more than two-thirds of the surgical team were women. The percentage of cooperative behaviors dropped steadily as the gender balance shifted toward men, reaching a low of 39% for all-male surgical teams, Jones and her colleagues report. But all-female teams weren’t necessarily ideal: Cooperative behaviors were roughly the same when female surgeons had mostly male, as opposed to mostly female, surgical teams.

“I don’t know that we would have ever noted that without this kind of study,” Wahr says. “And it makes a lot of sense. … Men see each other as rivals.”

De Waal agrees, noting that other primates do the same thing. “Chimpanzee interactions are all about power dynamics,” he says. Alpha males establish dominance by posturing over other males, and “females don't figure in that equation.”

This kind of work is “really important because when [surgical] teams don’t work well it has terrible outcomes,” says David Rogers, a pediatric general surgeon at the University of Alabama School of Medicine in Birmingham. But he thinks it’s worth emphasizing that the majority of communications Jones observed were cooperative. “It’s not like television. … What we do is not nearly so exciting.”