To Speak or Not to Speak: Factors Influencing Medical Students’ Speech and Silence in the Operating Room. Accepted for Publication

Purpose

Understanding why medical students hesitate or are encouraged to speak up will help improve their Operating Room (OR) assimilation and pedagogic experience. Our objective was to explore why medical students speak up or remain silent in the OR.

Method

This qualitative study utilized Constructivist Grounded Theory, building on Goffman’s theory of performance in the everyday. Using semi-structured interviews, the authors interviewed 37 participants from 4 groups (medical students, resident surgeons, attending surgeons and OR nurses) in 2022 about expectations for medical students’ speaking up and behaviors that encouraged or discouraged students’ speaking. The authors iteratively team-coded and analyzed transcripts to develop a conceptual model. Data were triangulated to generate a list of speech-encouraging behaviors for each group.

Results

Students’ decisions to speak or remain silent depended on their perception of the OR as a safe space and was influenced by three themes: consciousness of being evaluated, situational awareness, and interpersonal engagement with OR team members. Increased preparation helped students feel safer concerning evaluation and encouraged asking the best questions. Awareness of critical surgical moments, evidenced by the team’s mood, helped students identify appropriate times to speak. Informal communication with OR nurses and task performance encouraged student speaking, whereas fear of exhibiting a lack of knowledge, unawareness of critical moments, or attendings with negative reputations suppressed speaking. Reluctance to speak up was viewed as a threat to patient safety.

Conclusions

Medical students remain conflicted between engaging in the OR and their fear of evaluation. A key for improving students’ sense of safety is for surgeons and nurses to establish interpersonal relationships and to be more self-aware of the mood they set. Better case preparation by students coupled with assignments by OR team members of case-related tasks will help students assimilate into the OR and improve their learning.