Rudeness made residents proceed with cases they would otherwise have postponed

Design

prospective randomised blinded crossover study using objective structured clinical examinations at two centres

Population

79 anaesthesiology residents (PGY 2-4), September 2024 to April 2025

Primary outcome

decision to proceed with or postpone surgery in clinically ambiguous scenarios

Effect

odds of proceeding under incivility 2.25 (95% CI 1.07-4.74, P=0.03); no difference in situational awareness, communication or decision-making scores

Anaesthesiology residents in years 2 to 4 at two American academic centres each completed two simulated scenarios designed to sit in genuine clinical equipoise - a medically complex case and an ethical dilemma - in which proceeding and postponing were both defensible. They were randomised to interact with a standardised surgeon actor who was either collaborative or rude and dismissive. Blinded attending anaesthetists scored the decision and the performance. Seventy-nine residents entered the analysis.

Residents facing the uncivil surgeon were more than twice as likely to proceed with surgery (odds ratio 2.25, 95% CI 1.07-4.74, P=0.03). Their measured performance did not fall: situational awareness (P=0.50), communication (P=0.09) and decision-making (P=0.50) scores were statistically indistinguishable between conditions. Demographic variables and personality traits did not explain the effect.

That combination is the finding. If incivility had degraded performance, the answer would be resilience training. What happened instead is that the residents performed as well as ever and decided differently - the pressure did not make them worse clinicians, it moved the threshold at which they would say no. This is a simulation with 79 residents at two centres and it cannot show that patients came to harm. It does describe a mechanism that every anaesthetist recognises, and it puts the responsibility in the right place: on the behaviour, not on the person absorbing it.

• Recognise the pattern in yourself - the decision to proceed made under pressure feels identical to one made freely
• Make the postponement decision explicit and documented, with your reason, before the conversation with the surgeon rather than after
• Give trainees an escalation route that does not require them to win an argument alone - a named consultant to call
• Treat repeated incivility as a patient safety issue and report it through that route, not only as a professionalism complaint
• Where a case is genuinely equivocal, say so out loud; naming the equipoise makes the pressure visible

Why it matters

It shows the coercion working on the decision rather than on the competence, which is why better training would not fix it.

Don't overread it

A simulation study with standardised actors and 79 residents - it demonstrates a change in decisions under test conditions, not harm to patients.

The statistics, in plain English

An odds ratio of 2.25 with an interval of 1.07 to 4.74 only just clears 1.0, so the effect is real in this sample but its size is poorly pinned down - with 79 residents, it could be modest or large. The null performance results are underpowered too, and should not be read as proof that incivility does not affect performance; it is more accurate to say this study detected a change in decisions and not a change in scores.

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