CNN  — 

Whether patients have problems after surgery could depend on their surgeons’ behavior, a new study suggests.

The study, published Wednesday in the journal JAMA Surgery, found that patients were at higher risk of complications if their surgeons were more often reported by colleagues for “unprofessional behavior” in the three years leading up to the surgery.

“Having critical things happen at the exact right time is an essential function for those teams,” said study author Dr. William O. Cooper, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. “And to do that, people have to be able to talk with each other, show mutual respect and constantly be aware of what’s going on around them.”

In the study, 14.1% of patients whose surgeons had been reported by co-workers at least four times experienced medical or surgical complications, including subsequent infections, lung and kidney problems. The same was true for 10.7% of patients whose surgeons had zero reports. (Still, they weren’t statistically more or less likely to die, have reoperations or get readmitted to the hospital within a month’s time.)

The numbers – which come from more than 13,600 patients and roughly 200 surgeons at two academic medical centers – may seem like a small increase, Cooper said. But if they are representative of the country at large, “that could mean more than half a million additional complications every year, just teasing out the effects of these unprofessional behaviors … which also results in costs.”

Surgeons might be reported for a range of unprofessional conduct – like yelling at co-workers or disregarding hospital policies – that need not include examples of direct harm or neglect to patients. Rather, the data suggests that bad behavior could more broadly create an environment in which people don’t communicate effectively or are afraid to speak up or ask for help, Cooper said.

Although the study can’t show direct cause and effect, previous research has also linked negative behavior among surgeons to poorer performance and malpractice claims, according to another recent study whose author said these findings are hardly surprising.

“It’s not just how well you cut, sew and tie,” said surgical oncologist Dr. Alex Haynes, who was not involved in the study. “It’s how well you communicate, lead and explain that matters to how your patients do.”

‘Ingrained in the culture’

One surgeon “struck my fingers with a surgical instrument because I was not holding the retractor correctly,” cardiac surgeon Dr. Danny Chu recounts in a commentary published alongside the study.

That surgeon also flung tools across the room when handed the wrong ones, the editorial continues.

“Those behaviors were tolerated decades ago, and all incidents were kept behind closed doors,” Chu and his colleagues wrote. “A hostile workplace is unfortunately not uncommon in academic surgery departments.”

CNN spoke to several surgeons and trainees across various fields who said the climate can be toxic at times. But it can be hard to tell just by looking at colleagues, with some complaints seeming minor or arbitrary. And many unprofessional behaviors go completely unreported.

“There’s a huge culture of not reporting, period,” said one trauma surgeon, who requested not to be named, citing career concerns. “There’s a certain amount of harassment that you just deal with and keep going because you don’t want to appear weak.

“It’s hugely ingrained in the culture,” she said. At the same time, she added, the intensity, long hours and high stakes are expected parts of the job, setting the stage for other aspects of her work and close relationships she also finds fulfilling: “I trust my partners with my life and with my patients’ lives, and I can’t just get that type of camaraderie and partnership at any job.”

Others described a positive experience overall, like plastic and reconstructive surgeon Dr. Kavita Vakharia.

“I did have a unique surgical training experience,” Vakharia said. But she knows that her own positive experience may not speak for others’: Vakharia presented research last year finding that “sexual harassment, verbal harassment and abuse were prevalent in plastic surgery residency.” The research was prompted in part by the #MeToo movement, she added.

“A majority of residents … actually didn’t report it.”

Cooper agreed that many bad behaviors go under-reported: “We really think about these reports as being a tip of the iceberg of these behaviors but an important measure that we can then connect to patient outcomes.”

He also said his study found that female surgeons were less likely to get written up than their male colleagues. This was unexpected, he added, given that “women surgeons may perceive that they’re held to a different standard and are more likely to be reported.”

“It’s not that I believe this study proves that those perceptions are wrong,” he added. “While we didn’t find something [in this study], it doesn’t mean there isn’t a lot of work we need to do.”

Still, doctors say the field is changing for the better. The stereotype of the brusque surgeon, Haynes said, “is probably more historic than current. When we look at who are becoming surgeons now, in the 21st century, it’s very different than it was decades ago.”

But what to do with this data, he said – “that’s really the million dollar question.”

Rude awakenings

“Getting to the desired goal – whether it’s successfully treating a patient in the operating room or the hospital ward or even in the outpatient clinic – it really relies on not only individuals but also how individuals work together as a team,” said Dr. Jeff Brady, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality.

Brady said the agency collects its own data on hospital and health care climates – for example, through staff surveys – and conducts teamwork trainings through a curriculum it developed with the Department of Defense, called TeamSTEPPS.

Brady, who was not involved in the new research, said that “softer, more interpersonal things” aren’t always seen on the same plane as medical parameters – but the research reveals that it’s a matter of patient safety.

At Vanderbilt, Cooper said, work goes into “identifying the professionals who are outliers in terms of their behaviors and putting in place interventions to help them improve.” Most of the time, in his experience, “when you share data with professionals, they improve their performance.”

Even so, it may not always be that easy, Haynes said.

Get CNN Health's weekly newsletter

Sign up here to get The Results Are In with Dr. Sanjay Gupta every Tuesday from the CNN Health team.

“One of the biggest challenges is that the people who are often need that kind of help are the ones who are the least receptive to it,” he said.

For patients, who typically don’t have access to co-worker reports, Cooper said there’s a simpler message about finding the right surgeon for them.

“Patients are uniquely positioned to observe things about their surgeons,” he said. “If you notice something about the surgeon in the way they interact with you, your family or with their colleagues that is offputting or seems disrespectful, it’s important to recognize.”