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Physician Communication in the Operating Room a

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Kristin A. Kirschbaum , John P. Rask , Sally A. Fortner , Robert Kulesher , Michael T. Nelson , b

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Tony Yen & Matthew Brennan a

School of Communication, East Carolina University

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Department of Anesthesiology & Critical Care Medicine, University of New Mexico Health Science Center c

College of Allied Health Sciences, East Carolina University

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Department of Surgery, University of New Mexico Health Science Center

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Department of Obstetrics & Gynecology, University of New Mexico Health Science Center Published online: 02 Jun 2014.

Click for updates To cite this article: Kristin A. Kirschbaum, John P. Rask, Sally A. Fortner, Robert Kulesher, Michael T. Nelson, Tony Yen & Matthew Brennan (2014): Physician Communication in the Operating Room, Health Communication, DOI: 10.1080/10410236.2013.856741 To link to this article: http://dx.doi.org/10.1080/10410236.2013.856741

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Health Communication, 1–11, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2013.856741

Physician Communication in the Operating Room Kristin A. Kirschbaum School of Communication East Carolina University

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John P. Rask and Sally A. Fortner Department of Anesthesiology & Critical Care Medicine University of New Mexico Health Science Center

Robert Kulesher College of Allied Health Sciences East Carolina University

Michael T. Nelson Department of Surgery University of New Mexico Health Science Center

Tony Yen Department of Anesthesiology & Critical Care Medicine University of New Mexico Health Science Center

Matthew Brennan Department of Obstetrics & Gynecology University of New Mexico Health Science Center

In this study, communication research was conducted with multidisciplinary groups of operating-room physicians. Theoretical frameworks from intercultural communication and rhetoric were used to (a) measure latent cultural communication variables and (b) conduct communication training with the physicians. A six-step protocol guided the research with teams of physicians from different surgical specialties: anesthesiologists, general surgeons, and obstetrician–gynecologists (n = 85). Latent cultural communication variables were measured by surveys administered to physicians before and after completion of the protocol. The centerpiece of the 2-hour research protocol was an instructional session that informed the surgical physicians about rhetorical choices that support participatory communication. Post-training results demonstrated scores increased on communication variables that contribute to collaborative communication and teamwork among the physicians. This study expands health communication research through application of combined intercultural and rhetorical frameworks, and establishes new ways communication theory can contribute to medical education.

Correspondence should be addressed to Kristin A. Kirschbaum, PhD, School of Communication, East Carolina University, Greenville, NC 27858. E-mail: [email protected]

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Patient safety is of primary importance in health care systems. Current medical research demonstrates that patient safety increases when medical providers effectively communicate with each other (Awad et al., 2005; Kohn, Corrigan, & Donaldson, 2000; Lingard et al., 2004). Research conducted by the Institutes of Medicine (Kohn et al., 2000) discovered that miscommunication among providers causes a larger percentage of patient-care errors than providers’ lack of ability or incompetence. As a result of increased medical communication research, the majority of health care systems now require proof of communication competency at multiple levels of medical expertise. Examples of the medical communication requirements are numerous. In medical education, the governing boards for undergraduates—Association of American Medical Colleges (AAMC)—and graduates—Accreditation Council for Graduate Medical Education (ACGME)—both implemented communication competency requirements. Hospital accreditation boards also revised licensing requirements to require communication standards for healthcare providers. The operating room and surgical units are of specific concern in both medical education and hospitals. In obstetrical cases alone, communication problems were cited as a primary cause of 72% of perinatal deaths or permanent disabilities (Joint Commission, 2004). Obstetrical care is merely one surgical specialty out of dozens, yet within just this discipline almost 75% of all deaths and disabilities resulted from miscommunication among providers. While the statistics are alarming, they also point to new avenues of health communication research. This current study focuses on this new area of research to examine communication among operating room physicians. The research protocol (Kirschbaum, Rask, Brennan, Phelan, & Fortner, 2012) consists of six steps that collect data and conduct communication training with multidisciplinary groups of anesthesiologists, general surgeons, and obstetrician–gynecologists (obgyns). The protocol includes a communication intervention that is centered between two high-fidelity simulation sessions, and two measures of medical communication norms (Kirschbaum, 2012). Briefly, the communication intervention focuses on specific rhetorical choices made by physicians; the simulations allow the physicians to experience the rhetorical choices as a surgical team without risk of patient harm, and the communication norms are measured by survey responses collected at the beginning and end of the entire protocol.1 Results from this study contribute to the field of health communication in multiple ways. While a vast amount of research has been conducted on provider–patient communication, and many recent studies focus on nurses and/or how nurses communicate with physicians (Brinkert, 2011; Nicotera & Mahon, 2013; Zweibel et al., 2008),

1 The

research was conducted at a teaching hospital over 3 years.

this study specifically examines communication among anesthesiologists, surgeons, and obgyns. These operating room physicians frequently negotiate leadership roles for patient care with reliance upon cultural communication norms and priorities that vary widely among the medical specialties. For example, the anesthesiologists’ primary concern may be the airway and breathing of a mother who is giving birth, while the obgyns’ primary concern is the delivery and health of the newborn. The communication patterns among the physician groups reflect these contradictory agendas for patient care (Kirschbaum, 2012) based on latent cultural norms that contribute to language, rules, and traditions unique to each medical specialty.

MEDICAL CULTURE Definitions of culture are numerous and varied. However, a consensus recognizes that culture includes shared values, meanings, attitudes, language, customs, and assumptions that are culturally unique and passed from generation to generation (Bellot, 2011; Bolman & Deal, 2003; Gluck, 2010). While medical research commonly refers to medical culture, cultural communication scholars may be less comfortable with the terminology. A more inclusive definition of culture that is not identified by geography or national identification could be termed a structure or social system. Structuration theory uses these specific terms to explain the recursive reproduction of rules and resources that guide social norms and practices across time and space (Giddens, 1984). Within the conceptual frame of structuration, rules determine meaning and specify appropriate action, while resources determine how the rules continuously perpetuate social systems. As a structure, medicine contains rules and resources that repeatedly inculcate distinct cultural norms. Rules within medical culture include values and practices that reflect heightened sense of individualism (Kirschbaum, 2012), invulnerability (Hafferty & Franks, 1994), and denied susceptibility to stress (Nielsen & Mann, 2008). Resources that transmit these rules are evident in medical education systems that perpetuate medical culture through language (extensive abbreviations and acronyms), clothing (white coats and scrubs), and specified norms of behavior (adherence to hierarchical structure and communication style). The rules and resources that inform medical culture also contribute to communication errors and conflict. Researchers found that shared leadership, importance of hierarchy, and multispecialty medical teams contribute to miscommunication and conflict among physicians (Brinkert, 2011; Graham, 2009; Sarcevic et al., 2011; Zweibel et al., 2008). These conflicting cultural systems are acute among physicians in the operating room where patient care needs rapidly change, and competition for the decision-making role is common. An examination of leadership in trauma teams (Sarcevic

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et al., 2011) found that multidisciplinary leadership with shared decision making increased conflict and reduced team efficiency. Sarcevic et al. (2011) specifically discovered trauma teams’ inefficiency was caused by lack of collaboration within the surgical team that resulted in patient errors and unnecessary procedures. Gershon et al. (2004) also examined communication associated with conflict and adverse patient care. The researchers discovered two major themes: (a) Cultural adherence to rigid hierarchy contributes to silence rather than participatory teamwork communication, and (b) lack of communication about cultural values contributes to inconsistent behavior among medical teams. Without awareness of diverse cultural attributes, surgical physicians remain in conflict and resort to silence and/or competitive communication tactics that result in adverse patient care. Silenced team members are particularly detrimental to patient care in the operating room. If an individual observes problems or discrepancies during a surgical procedure but fails to voice concern, the potential for error can be deadly. Sexton et al. (2006) determined that silence commonly occurred during obstetrical cases over disagreements in patient care. Silence characterizes avoidant conflict style, and is associated with attempts to protect self-image within strong hierarchical structures. Graham (2009) observed and analyzed dialogue between medical students, nurses, and physician and found that avoidance and nonparticipatory communication, or silence, resulted from adherence to rigid hierarchal structures. Specifically, nurses relied on their superior professional rank to exert dominance and silence medical students. However, nurses rarely challenged physicians and more frequently remained silent during dialogue with physicians, unless directly questioned (Graham, 2009). Relative rank of medical student, nurse, and physician are clear, but physicians share a similar position within the cultural hierarchy of medicine. In many cases physicians bear ultimate responsibility for surgical patient outcomes; therefore, it is critical to learn more about variables of medical culture that perpetuate conflict, silence, and miscommunication among physicians. Cultural Variables and Physician Communication A few recent studies measured latent communication variables and conflict among physicians. Survey items in the Practices in the Operating Room (PRIOR) measure variables of relative autonomy or interdependence, concerns for self or others during conflict, and communication behaviors (dominating, avoiding, and integrating) that arise during conflict (Kirschbaum, 2012). The three categories are relevant to miscommunication among operating room physicians in multiple ways. First and foremost, physicians are trained to function independently within the highly autonomous medical culture. The ability to excel and surpass others with skills and knowledge is highly rewarded in medicine

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(Hafferty & Franks, 1994). However, the opposite attributes of interdependence, teamwork, and collaboration contribute to more effective communication and patient care in the operating room. In previous research, positive correlations were found among independent self-construal, self-face concern, and dominating conflict style (Oetzel & Ting-Toomey, 2003, Oetzel et al., 2001). Since medical education inculcates autonomy, the categories of items in the PRIOR (Kirschbaum, 2012) help determine whether operating room physicians who are more independent also use dominance to protect self-image and silence others. Face-negotiation theory. The three categories of cultural variables measured in the PRIOR are used in most face-negotiation research. Face-negotiation theory (TingToomey, 2005) has been widely utilized to measure cultural communication and conflict. In more recent application, face-negotiation has framed research on work-group dynamics, and on conflict negotiation in corporate settings, with the goal of improved team performance (Oetzel, McDermott, Torres, & Sanchez, 2011; Ting-Toomey, 2007). Previous and current face-negotiation uses reinforce the value of the theoretical frame to measure latent cultural variables and conflict behaviors among operating-room physicians. Variables measured in the majority of face-negotiation research are conflict management style, self-construal, and face concern. Conflict styles are measured by survey responses to stated disagreements. Three categories of conflict styles are measured: dominating, integrating, and avoiding (Ting-Toomey, 2005). Dominating is associated with competition and polarized wins or losses during disagreement. Avoiding is associated with evasion and silence during disagreement. Integrating is associated with collaboration and cooperation during disagreement (Ting-Toomey, 2005). A second variable, self-construal, is measured through two categories of affiliation relative to others: independence or interdependence (Markus & Kitayama, 1991). Independent self-construal is associated with autonomy and individual success, while interdependent self-construal is associated with reliance upon others and group success. The third facenegotiation variable, face concern, is measured by responses to identity protection during disagreement or conflict (TingToomey, 2005). Three categories measure face concern: selfface, other-face, and mutual-face. Self-face is associated with protection of the individual identity or self during conflict, other-face is associated with protection of another’s identity during conflict, and mutual-face is associated with protection of a group identity during conflict. Analysis from previous face-negotiation research (Kirschbaum, 2012; Oetzel & Ting-Toomey, 2003; Oetzel et al., 2001) demonstrated inconsistent measurement of mutual-face concern. As a result, that category of face concern has been excluded from analysis in this and other studies. The survey data collected in the PRIOR are part of a multistep research protocol. A communication training

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intervention and two simulated operating-room cases are also part of the protocol. The communication training is the centerpiece of the protocol to provide specific rhetorical instruction and engender collaborative communication among the physicians.

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Medical Communication Training Physicians and other medical providers are well qualified to provide excellent patient care. But those same medical providers rarely receive adequate training in communication. Due to increased accreditation requirements and revised practice standards (Accreditation Council for Graduate Medical Education, 2001; American College of Obstetrics and Gynecology, 2010; Joint Commission, 2010); new communication training programs exist for medical providers. However, there are two common hindrances in many medical communication training programs: lack of attention to latent variables, and lack of multidisciplinary training. Attention to latent variables. The first issue is inattention to underlying or latent variables. Most medical training programs focus on the mechanics of improved teamwork and patient safety (Lyndon, Zlatnik, & Wachter, 2011; Nielsen & Mann, 2008; Pettker et al., 2011; Pronovost et al., 2008); however, attention to the mechanics or symptoms that result from miscommunication do not address latent variables. In other words, the interventions bandage the wound, but do not “cure” the underlying malady or communication disorder. Some recent research with nurses attends to latent variables. Nicotera and Mahon (2013) used structurational divergence to examine contributing communication factors among nurses and other medical providers. The study determined that divergent structures of meaning contributed to conflict and miscommunication. Nicotera and Mahon (2013) suggested that future research focus on joint problem solving, stress management, and a dialogical approach (focus on dialogue) to handle conflict. Brinkert (2011) likewise proposed a dialogical approach with nurses in which narrative training helped nurses identify contributing factors and then suggested improved communication patterns based on dialogue. In both nursing studies, an examination of latent cultural values resulted in dialogical suggestions or language choices to improve communication among nurses and other medical providers. However, nursing culture is different from physician culture. Minehart et al. (2012) specifically examined culture and dialogue among physician groups of anesthesiologists and obstetricians. The researchers reported that both physician groups use statements, observations, and opinions during procedures. However, variance between the two groups existed since obstetricians asked questions while anesthesiologists did not. Minehart et al. (2012) termed the

communication patterns “advocacy and inquiry.” Advocacy referred to statements and opinions, while inquiry referred to questions (Minehart et al., 2012). The researchers suggest that combined use of advocacy and inquiry leads to better communication during surgical procedures, which in turn results in shared understanding of patient cases. Both nursing and physician studies focus on dialogue and language choices. Specific words and language are suggested to positively influence communication patterns and patient care. The communication intervention at the heart of the multistep protocol in this present study also emphasizes dialogue and specific language choices to address latent structural patterns of communication among operating-room physicians and to contribute to improved patient care. Multidisciplinary training. The second concern with many medical communication interventions is lack of multidisciplinary training. Most communication training is conducted with isolated groups of medical providers. Unfortunately, individualized instruction results in lost opportunities. At the most basic level, dialogue among physicians from various surgical specialties increases awareness of cultural practices and communication patterns that are prevalent in other disciplines. Additionally, multidisciplinary training contributes to shared meaning across the various medical disciplines that increase collaboration and collegiality. Multidisciplinary training is integral in this current study. The six-step protocol (Kirschbaum & Fortner, 2012) was used to conduct training sessions with multiple groups of two anesthesiologists, general surgeons, or obgyns. Two of the steps in the protocol engaged the surgical physicians in patient cases that occurred in a high-fidelity simulation center. The physicians experienced firsthand how (mis)communication affects patient care positively and negatively. The step at the center of the protocol consisted of communication instruction in rhetorical choices. The instructional session provided knowledge about communication and rhetoric to open new avenues of communication among the physicians from various disciplines and further increase shared meaning and collegiality among the physicians. The remaining two steps in the protocol collected survey data from the physicians using the PRIOR (Kirschbaum, 2012) to measure latent cultural variables at the beginning of the protocol and any changes in variables that occurred as a result of participation. Those survey data inform the seven hypotheses that guide this present study: H1: Scores on interdependent self-construal will increase after physicians complete the protocol. H2: Scores on independent self-construal will decrease after physicians complete the protocol. H3: Scores on self-face concern will decrease after physicians complete the protocol.

PHYSICIAN COMMUNICATION IN THE OPERATING ROOM

H4: Scores on other-face concern will increase after physicians complete the protocol. H5: Scores on dominating conflict style will decrease after physicians complete the protocol. H6: Scores on avoiding conflict style will decrease after physicians complete the protocol. H7: Scores on integrating conflict style will increase after physicians complete the protocol.

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METHOD Following a six-step protocol, multidisciplinary groups of physicians (two from each surgical specialty) participated in communication training and associated data collection. The data consisted of pre- and post-training survey responses that measured latent communication variables associated with culture and conflict. The protocol was completed in 2 hours and followed university-approved institutional review board (IRB) protocol. Participants The physicians were recruited from a teaching hospital in the Southwestern United States, and did not receive compensation for participation. Specific physician groups (anesthesiologists, general surgeons, and obgyns) were selected to represent medical providers of similar hierarchical position who commonly co-manage patient cases in the operating room. In total, 85 physicians participated in the study. The sample included 43 anesthesiologists, 30 general surgeons, and 12 obgyns. By gender, the sample was comprised of 41 men, 43 females, and one nonidentified gender. The majority (73%) of participants were between 26 and 32 years of age, and 24% were between 33 and 39 years. The remaining 3% were either 25 or younger, 40–46 years of age, or 47 or older: 1% in each age group. The majority of the participants self-identified as White/Caucasian (57%), with an additional 13% Hispanic/Latino, 12% Asian, 5% Multiethnic, 4% African American, and 9% did not respond. Procedure Four physicians participated in each training session. Two groups of two physicians from either anesthesiology and general surgery or anesthesiology and obgyn participated in each session. The training sessions were scheduled at least one day apart, and each six-step protocol was completed within 2 hours. In the first step of the protocol, physicians were introduced to the study and to each other. All participants were informed of standard consent procedures and completed the pre-training administration of the PRIOR (Kirschbaum,

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2012). All consent forms and surveys were administered in paper format and collected upon completion. During the second step, general processes and procedures for work in the high-fidelity simulation (sim) center were explained to the four physicians. Each physician group of two was then given a typed scenario that described an emergent patient case that would engage the physicians in the sim center. The cases represented actual operating-room patient cases and were written by a collaborative team of multidisciplinary surgical physicians to present distressed patients with rapidly evolving medical complications. Each surgical team was intentionally given incomplete patient information that necessitated communication of critical details and teamwork among all the physicians in order to save the patient. Patient responses to questions, medical procedures, and administered medications were monitored by senior surgical physicians. The simulation was also observed from a remote location to collect examples for use during the communication instruction, which followed in the third step of the protocol. The simulation in step 2 of the protocol lasted approximately 20 minutes. Step 3 in the protocol consisted of instruction in invitational medical rhetoric (IMR). Specific terminology used in IMR was modified from a communication text (Foss & Foss, 2003) and standardized in a PowerPoint presentation. The four physicians jointly participated in the IMR instruction. Each communication session was customized with examples from the simulation conducted in step 2 of the protocol. In addition to the examples, physicians also recalled and discussed personal experiences in which rhetorical language choices provoked either positive or negative responses. The physicians’ experiences, both positive and negative, further facilitated discussion of latent cultural variables that contribute to (mis)communication. IMR instruction consisted of four specific steps. 1. A contemporary definition of rhetoric2 as words and language choices, with explanations of verbal/nonverbal components and common communication reactions to rhetorical choices. 2. A discussion of default rhetorical choices that identified language patterns and responses to specific scenarios that occur in the operating room. Attention was directed to rhetorical choices that result in dominating, alienating, and/or silencing others. 3. An introduction to IMR as an alternative rhetorical pattern. Further explanations and examples demonstrated how rhetorical choices can contribute to inclusive communication patterns and responses that invite rather than polarize or silence other surgical team members. 2 The term rhetoric was used since the physicians’ connotation of the term was more scientific than for communication, and therefore resulted in wider acceptance.

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4. An introduction to a mnemonic device (ABCs) to remember and facilitate rapid recall of IMR during operating-room cases and other rapidly evolving contexts. The physicians were continuously asked to identify scenarios, rhetorical choices and associated responses throughout step 3 of the protocol. The active participation was particularly important to help the physicians engage in the instruction. To further support active learning, physicians also personalized their new rhetorical language. The physicians experimented by speaking the alternative words and phrases aloud to test individual comfort level and responses. The physicians were asked to use their new words and phrases in the subsequent simulation session. IMR instruction in step three was completed in approximately 20 minutes. The fourth step of the protocol consisted of another simulation session with a different patient case. The second case was also written by a multidisciplinary team of physicians and based on an actual operating-room case. As in the first simulation, incomplete patient briefing was intentionally given to each surgical team, requiring collaborative communication among all four physicians for best patient outcome. The second simulation was also monitored by senior physicians, and was remotely observed to note rhetorical usage and subsequent patient outcomes. The simulation conducted in step 4 of the protocol lasted approximately 20 minutes. The fifth step of the protocol consisted of the posttraining administration of the PRIOR (Kirschbaum, 2012) to measure any changes in latent cultural and communication variables that occurred as a result of participation in the training protocol. The sixth step of the protocol consisted of a debriefing session with the physicians. The senior physicians and communication expert jointly debriefed the medical decisions and rhetorical patterns that occurred in both simulated patient cases. Specific examples were cited from the simulation sessions and IMR instruction to facilitate discussion and provide specific feedback that reinforced positive choices. The collective debrief conducted by physicians and a communication scholar in the final step of the protocol exemplified and further reinforced collaboration and teamwork among disciplines. Measures Latent cultural communication variables were measured by survey responses to the PRIOR (Kirschbaum, 2012). Items in the PRIOR measure three categories of face-negotiation variables (Ting-Toomey, 2005), modified by a group of physicians to specifically represent hospital and operating-room contexts. The PRIOR (Kirschbaum, 2012) is completed in approximately 5 minutes. In total, 42 items are included in the PRIOR (Kirschbaum, 2012). Self-construal is measured with 14 items: Seven correspond to independence and seven correspond to interdependence. An example of a question that measures

independence is, “It is important for me to be able to act independently in surgery.” An example of a question that measures interdependence is “I consult with other physicians during surgery.” Ten items measure face concern, with five items each to measure self-face and other-face. Examples of items are “I want to maintain my dignity in front of other surgical team members during disagreements” for self-face, and “During disagreements, I pay attention to helping the surgeon feel respected” for other-face. Eighteen items measure conflict style with six items to measure each conflict style: dominating, avoiding, and integrating. An example of an item that corresponds to dominating is “I sometimes use my power in the operating room to win a competitive situation.” An example of an integrating conflict style item is “I try to find a middle course to resolve an impasse.” An example of an item that corresponds to avoiding conflict style is “I generally keep quiet and wait for things to improve.” Measurement of all items was based on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. The survey used two unique formats with items that reflect the specific physician group. Surveys administered to anesthesiologists designated anesthesiologists as decision makers, with surgeons named as the other group of physicians. Decision makers and the other group of physicians are switched in the second version of the PRIOR (Kirschbaum, 2012), which was administered to general surgeons and obgyns. Examples of the formatted wording changes in the two versions are that “Once an anesthesiologist makes a decision . . .” was administered to anesthesiologists and “Once a surgeon makes a decision . . .” was administered to surgeons and obgyns. Demographic data were collected with eight items. Questions corresponded to gender, age, title (attending physician or resident), position (surgery or anesthesiology), and ethnic background. All copies of the PRIOR (Kirschbaum, 2012) were completed in paper format. The pre- and post-training data were entered into an electronic spreadsheet (Excel) with demographic data coded for numeric values. Initial data screening of the Excel spreadsheet confirmed that the data were complete. Once verified, the data were imported into SPSS 20 for further analysis.

RESULTS Since the sample size for each physician group varied— anesthesiologist (n = 43), general surgeon (n = 30), and obgyn (n = 12)—the data were analyzed for homogeneity of variance. Results of Levene’s test indicated nonsignificant variance among all three physician groups. Analyses of variance (ANOVAs) were then conducted to test for significant variance between the physician groups on the seven latent variables measured in the PRIOR. Mean scores, standard deviations, and ANOVA results from the pre-training data are reported in Table 1.

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TABLE 1 Mean Scores, Standard Deviations, and ANOVA Results From Pre-Training Data Anesthesiologist Mean (SD); Range

General Surgeon Mean (SD); Range

ObGyn Mean (SD); Range

ANOVA Results

3.66 (.60); 3.47–3.84 4.04 (.42); 3.91–4.17 3.02 (.63); 2.82–3.22 2.59 (.67); 2.38–2.80 2.97 (.56); 2.75–3.18 2.38 (.70); 2.17–2.59 3.31 (.48); 3.17–3.46 2.62 (.70); 2.41–2.84

3.60 (.59); 3.37–3.81 4.19 (.42); 4.03–4.34 3.07 (.78); 2.78–3.36 2.97 (.67); 2.38–2.80 3.26 (.55); 2.97–3.55 2.23 (.76); 1.94–2.51 3.62 (.62); 3.39–3.46 2.71 (.67); 2.46–2.96

3.63 (.42); 3.36–3.90 4.05 (.32); 3.85–4.25 2.70 (.60); 2.32–3.08 2.68 (.57); 2.32–3.04 3.28 (.46); 2.99–3.58 2.19 (.46); 1.90–2.49 3.31 (.51); 2.98–3.63 2.38 (.31); 2.18–2.57

F(2,82) = 0.13, p = .88 F(2, 82) = 1.27, p = .29 F(2, 82) = 1.31, p = .28 F(2, 82) = 2.94, p = .06 F(2, 82) = 2.33, p = .11 F(2, 82) = 0.59, p = .56 F(2, 82) = 3.26, p = .04 F(2, 82) = 1.15, p = .32

Variables

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Independence Interdependence Self-face Other-face Mutual-face Dominate Integrate Avoid

Six of the seven latent variables measured in the PRIOR resulted in nonsignificant variance among the three physician groups. ANOVA results indicated significant variance on integrating conflict style: F(2, 82) = 3.26, p = .04. Tukey post hoc tests indicated anesthesiologists (3.31 ± 0.48 min, p = .046) scored significantly lower than general surgeons (3.62 ± 0.62 min, p = .046) on integrating conflict style before participation in the six-step training protocol. The post-training data were also subject to ANOVA to determine if there was significant variance among the physician groups on the seven latent variables. Mean scores, standard deviations, and ANOVA results from the post-training data are reported in Table 2. ANOVA results indicated nonsignificant variance on all seven latent variables.

Paired-sample t-tests were then conducted to test the seven hypotheses that significant variance occurred on latent cultural communication variables after completion of protocol. Mean scores from all physicians were averaged for aggregate scores on six of the seven latent variables in both pre-training and post-training data sets to test for statistical variance. Since ANOVA results indicated significant variance on integrating style in the pre-training data, those preand post-training data were analyzed separately for each physician group. The analyses were conducted using Bonferroni adjusted alpha levels of .005 per test (.05/10) to adjust for multiple comparisons. Results of all t-tests are reported in Table 3.

TABLE 2 Mean Scores, Standard Deviations, and ANOVA Results From Post-Training Data

Variables Independence Interdependence Self-face Other-face Dominate Integrate Avoid

Anesthesiologist Mean (SD); Range

General Surgeon Mean (SD); Range

ObGyn Mean (SD); Range

ANOVA Results

2.94 (.91); 2.66–3.22 4.23 (.50); 4.08–4.39 3.01 (.81); 2.76–3.25 2.51 (.74); 2.28–2.74 2.36 (.75); 2.13–2.59 3.56 (.50); 3.41–3.71 2.41 (.83); 2.16–2.67

2.93 (1.06); 2.54–3.30 4.32 (.48); 4.14–4.50 3.08 (.87); 2.76–3.39 2.84 (.67); 2.59–3.09 2.44 (.90); 2.11–2.78 3.72 (.72); 3.45–3.99 2.46 (.84); 2.14–2.77

2.54 (1.08); 1.86–3.23 4.42 (.42); 4.15–4.68 2.98 (.85); 2.44–3.52 2.92 (.65); 2.50–3.33 2.72 (.63); 2.32–3.12 3.61 (.69); 3.17–4.05 2.56 (.80); 2.28–2.62

F(2,82) = 0.83, p = .44 F(2, 82) = 0.75, p = .47 F(2, 82) = 0.08, p = .92 F(2, 82) = 2.68, p = .08 F(2, 82) = 1.01, p = .37 F(2, 82) = 0.64, p = .53 F(2, 82) = 0.15, p = .86

TABLE 3 t-Test Results to Compare Mean Scores Before and After Completion of Training Protocol∗

Variable Independence Interdependence Self Other Dominating Avoiding Integrating—all Integrating—anesthesiologist Integrating—general surgeon Integrating—obgyn ∗ Results

Pre-training Mean (SD)

Post-training Mean (SD)

t-Test Result

3.63 (.57) 4.09 (.41) 2.99 (.69) 2.74 (.67) 2.30 (.69) 2.62 (.65) 3.42 (.55) 3.25 (.52) 3.46 (.62) 3.31 (.51)

2.88 (.99) 4.29 (.48) 3.03 (.82) 2.69 (.72) 2.44 (.79) 2.45 (.80) 3.62 (.61) 3.51 (.52) 3.69 (.74) 3.61 (.69)

t(84) = –8.83, p = .000 t(84) = 3.60, p = .001 t(84) = .64, p = .525 t(84) = –.80, p = .427 t(84) = 2.19, p = .031 t(84) = 4.58, p = .039 t(84) = –2.10, p = .000 t(28) = –3.44, p = .002 t(15) = 1.98, p = .06 t(11) = –3.53, p = .005

reflect use of Bonferroni adjusted alpha levels of .005 per test (.05/10).

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A paired-sample t-test indicated the physicians measured significantly higher on interdependent self-construal after participation in the training protocol, t(84) = 3.6, p < .001, d = 0.41. Thus, the first hypothesis was supported: Scores on interdependent self-construal increased for the surgical physicians who participated in the training protocol. Paired-sample t-test results also indicated the surgical physicians measured significantly lower on independence after participation in the six-step training protocol, t(84) = –8.83, p < .001, d = 1.10. Thus, the second hypothesis was also supported: Scores on independent self-construal decreased for physicians who participated in the training protocol. Paired-sample t-test results for both dimensions of face concern were nonsignificant. The average mean scores increased slightly on self-face, t(84) = .64, p = .525, and decreased slightly on other-face, t(84) = –.80, p = .427; therefore, the third and fourth hypotheses were not supported. Paired sample t-test results for the three dimensions of conflict style were mixed. The fifth hypothesis stated that scores on dominating conflict style would decrease after physicians participated in the training protocol. Average physicians’ scores on dominating measured higher after participation in the training protocol, t(84) = 2.19, p = .031. Therefore, the fifth hypothesis was not supported. The sixth hypothesis stated that scores on avoiding conflict style would decrease after surgical physicians participated in the training protocol. Paired sample t-test results on avoiding demonstrated lower scores, t(84) = 4.58, p = .039, d = 0.23, but not at a significant level due to Bonferroni adjustment; thus, the sixth hypothesis was not supported. The seventh hypothesis stated that integrating conflict style would increase as a result of participation in the training protocol. Paired-sample t-tests that combined the three physician groups indicated significantly higher scores on integrating, t(84) = –2.10, p < .001, d = .50. Integrating conflict style was also analyzed by individual physician group as a result of variance obtained from pre-training ANOVA results. Anesthesiologists, t(84) = –3.44, p = .002, d = .64, and obgyns, t(84) = –3.53, p = .005, d = 1.25, measured significantly higher on integrating. General surgeons’ scores did not increase significantly after participation in the training protocol, t(84) = 1.98, p = .06; thus, the seventh hypothesis was partially supported.

DISCUSSION The purpose of this study was twofold: first, to measure latent cultural variables associated with miscommunication among operating-room physicians, and second, to determine whether a multistep, multidisciplinary training would significantly affect the measures of latent cultural communication variables. The variables were measured through surveys that were collected at the beginning and end of a six-step research

protocol employed with multiple groups of operating-room physicians over 3 years. Other steps of the protocol consisted of a rhetorically focused communication intervention that was centered between two operating-room simulations that replicated life-threatening patient cases. Results of the study indicated significant variance on three latent variables. Most notable were changes on dimensions of self-construal. Data from anesthesiologists, surgeons, and obgyns who participated in the six-step training protocol indicated significant increase in scores on interdependence and significant decrease in scores on independence, with a large effect size on independence (d = 1.10). These two dimensions of self-construal were measured with separate sets of items, yet both dimensions resulted in significant variance toward increased teamwork communication. Since interdependence is associated with participatory teamwork among group members and independence is associated with autonomous function within groups (Markus & Kitayama, 1991), the directional variances indicate that the training sessions altered latent cultural variables to support more participatory communication and teamwork among the surgical physicians. Self-construal that reflects participation and teamwork is associated with improved group function and effectiveness. Oetzel, McDermott, Torres, and Sanchez (2011) found that higher interdependent self-construal is positively associated with positive interaction climate. Positive interaction climate includes respectful communication, consensual decision making, and participation, which in turn result in satisfaction and effectiveness. Since the physician data in this current study demonstrated increased interdependence and decreased independence, the results suggest that these surgical physicians are more likely to engage in communication that contributes to positive climate and participatory teamwork than before IMR training. Results on measures of integrating conflict style were also noteworthy. Significant variance in pre-training scores on integrating style resulted in separate analyses for each physician group. An examination of mean scores depicted in Table 3 indicates that the six-step training protocol raised scores for anesthesiologists and obgyns to match mean scores of general surgeons on integrating style. In pre-training data, the general surgeons measured significantly higher than anesthesiologists and obgyns, hence the significant ANOVA results and subsequent individual analyses. The t-test results from the separate analyses demonstrated significant variance from pre- to post-training scores for anesthesiologists and obgyns with medium to large effect. Although the t-test resulted in nonsignificant variance for general surgeons, the post-training ANOVA analysis also resulted in nonsignificant variance among the three physician groups on integrating style. In other words, after participation in the six-step training protocol, all physicians’ scores were at the same approximate mean value on integrating style, which was significantly higher than pre-training scores.

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Integrating conflict style represents collaborative communication and teamwork (Ting-Toomey, 2005). Therefore, higher and more equivalent scores on integrating conflict style indicate the value of the protocol to increase collaborative communication and further unify multidisciplinary surgical physicians. Both Minehart et al. (2012) and Sarcevic et al. (2011) determined that collaboration is necessary for shared understanding of patient cases and cohesive plans of action. The physicians’ equalized scores on integrating style in the post-training data further support the value of the sixstep protocol to alter latent cultural variables and increase collaborative communication, which in turn increases shared meaning to improve patient care.

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Limitations, Strengths, and Implications of the Study While this study has a number of strengths, limitations also exist. The lack of a control group of physicians is one specific limitation. From an experimental perspective, a control helps determine if the intervention is the only causal agent for change. However, research with operating-room physicians involves complications that do not exist with other human subjects. Anesthesiologists, general surgeons, and obgyns are busy, and their time is expensive. It is exceedingly difficult to schedule these physicians into 2-hour blocks of time required for the multidisciplinary training. The likelihood that these physicians would agree to participate in a control group that would not gain increased knowledge and skills is extremely low. Another limitation is the possibility of response bias. With a 2-hour window between pre-and post-training measures, it is possible that the physicians were sensitized to more collaborative-oriented responses as a result of the training. Although response bias may have contributed to significant variance in scores, the physicians’ reflection on communication patterns and subsequent realization that alternative language choices could facilitate better patient care is itself a positive result. One way to address response bias in future studies is an inclusion of longitudinal data in the study design. The physicians who participate in future research could be followed to determine how the six-step protocol affected their practice in the long term. Observation of these physicians in the operating room might not be conclusive since the physician schedules vary extensively. But repeated surveys for longitudinal data could be administered in addition to repeated training sessions with the physicians. Although access to these physicians is limited, follow-up training could provide even more comprehensive knowledge. In addition to these few limitations, this study has a number of strengths. First, the integration of distinct communication frameworks and methodologies adds to the field of health communication research. The communication intervention (IMR) relies on rhetorical instruction to offer physicians alternative language choices that can enhance

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communication in the operating room. In addition, the analysis relies on an intercultural framework (PRIOR) to measure latent cultural communication variables. The combined strengths of rhetorical instruction and intercultural quantitative measurement create a comprehensive understanding and analysis of the nuances and variables that hinder physician communication in the operating room. Not only does this study offer new insight for medicine, it expands the existing boundaries of health communication research through integration of divergent paradigms and methodologies. Another strength of this study is the multidisciplinary physician training. Through joint participation in the protocol, physicians from anesthesia, surgery, and obgyn gained knowledge of others’ rhetorical practices, became aware of challenges encountered by other surgical team members, and experienced increased collegiality. The physicians’ greater knowledge and awareness support future discussion and understanding of patient cases to provide unified plans of action proposed by Minehart et al. (2012). The increased knowledge and awareness, combined with alternative rhetorical choices, help improve collaborative communication among surgical physicians and promote effective patient care. Finally, the focus on physicians who co-manage patients in the operating room provides important new information. Graham (2009) found that communication among nurses, physicians, and medical students resulted in dominance and consequent silence. However, anesthesiologists, surgeons, and obgyns are all physicians. The unanticipated variance on dominating found in this study supports further study of communication among operating-room physicians. Instead of the inverse relationship found in other populations, increased dominating and decreased avoiding may contribute to more effective teamwork among physicians. In addition to increased sample size and longitudinal studies, future research could consider other influences and latent cultural variables to help further contributions in both communication and medicine.

Conclusion The six-step protocol used in this study makes several important additions. First, measurement of latent variables that influence communication patterns offers more comprehensive understanding of the dynamics that influence (mis)communication among physicians. Second, multidisciplinary training offers opportunities for physicians of different disciplines to communicate and learn more about each other in non-life-threatening contexts. Third, the combination of high-fidelity simulation and rhetorical instruction offers a multimodal approach to help the physicians experiment with, and then integrate, new communication practices.

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In addition, this study demonstrates how physicians can learn to collaboratively communicate on multidisciplinary surgical teams. Rather than traditional medical education, which emphasizes autonomy and independence (Hafferty & Franks, 1994), the six-step protocol used in this study offers new resources to inculcate new rules (Giddens, 1984) in a new generation of physicians. Changes in latent cultural communication variables suggest that medical social structures can be altered toward cultural practices that are more conducive to collaborative communication and teamwork. The structural shifts suggested through this study are strengthened by intersections of disparate communication disciplines that combine to expand the boundaries of previous health communication scholarship.

ACKNOWLEDGMENTS The authors acknowledge the numerous physicians who participated in this study. Finally, thank you to all the individuals involved in this study who helped each session run smoothly: Your contributions are immeasurable.

FUNDING Financial contributions from the Father Meldon Hickey Fund, and the Departments of Anesthesiology & Critical Care Medicine and Obstetrics & Gynecology were integral to the completion of this study.

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