REVIEW

CURRENT
OPINION How to communicate between surgeon
and intensivist?
Giovanni Misseri, Andrea Cortegiani, and Cesare Gregoretti

Purpose of review
Communication and teamwork are essential to enhance the quality of care, especially in operating rooms
and ICUs. In these settings, the effective interprofessional collaboration between surgeons and intensivists
impacts patients’ outcome. This review discusses current opinions and evidence for improving
Downloaded from https://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3hIW04IhZ9AvNyXiDskTJpGAYXztNG71dMzsxvxmZhgI= on 04/12/2020

communication strategies and the relationship between surgeons and intensivists/anesthesiologist.

Recent findings
Effective teamwork has been demonstrated to improve patient outcome and foster healthier relationships
between professionals.
With the expansion of new medical superspecialist disciplines and the latest medical developments, patient
care has been put through a progressive fragmentation, rather than a holistic approach. Operating theaters
and ICU are the common fields where surgeons and anesthesiologists/intensivists work. However,
communication challenges may frequently arise. Therefore, effective communication, relational
coordination, and team situation awareness are considered to affect quality of teamwork in three different
phases of the patient-centered care process: preoperatively, intraoperatively, and postoperatively.
Summary
Although limited, current evidence suggests to improve communication and teamwork in patient
perioperative care. Further research is needed to strengthen the surgeon–intensivist relationship and to
deliver high-quality patient care.
Keywords
anesthesiology, communication, patient-centered care, perioperative care, surgeon–intensivist relationship,
teamwork

INTRODUCTION actions improving interprofessional dynamics in

Odi et amo. Quare id faciam fortasse requiris. Nescio, sed
fieri sentio et excrucior [I hate and I love. Why I do this
perhaps you ask. I know not, but I feel it happening
and I am tortured] [1]. In this conflicting declaration
of emotions, Catullus poetically expresses his
contradictory feelings for his beloved Lesbia.
Long-lasting relationships, such as the one between
intensivist and surgeon, are permeated with alter-
nating agreements, disagreements, spirit of cooper-
ation, or obstruction to communication. Therefore,
teamwork and communication are critical elements,
and a favorable working environment is fundamen-
tal to improve surgical team performance, quality of
care, and patient safety and satisfaction.
Although the science of teamwork and commu-
nication has witnessed a great ascent in medical
literature, information on teamwork implementa-
tion and communication between intensivists and
surgeons is either lacking or of poor quality. We
review hereby the existing evidence and propose
patient perioperative care.
TEAMWORK AND COMMUNICATION
WITHIN HEALTHCARE PROFESSIONALS
Acute care and critical illness have to be considered a
&&
continuum of connected events [2 ]. Critical situa-
tions are usually preceded by a series of undetected
changes in vital and clinical signs. Once emergency
is identified, the patient undergoes multiple
Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.),
Section of Anesthesia, Analgesia, Intensive Care and Emergency, Poli-
clinico Paolo Giaccone, University of Palermo, Palermo, Italy
Correspondence to Cesare Gregoretti, Department of Surgical, Oncol-
ogical and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analge-
sia, Intensive Care and Emergency, Policlinico Paolo Giaccone,
University of Palermo, via del vespro 129, 90127 Palermo, Italy.
E-mail: c.gregoretti@gmail.com
Curr Opin Anesthesiol 2020, 33:170–176
DOI:10.1097/ACO.0000000000000808

www.co-anesthesiology.com Volume 33  Number 2  April 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 How to communicate between surgeon and intensivist? Misseri et al.
KEY POINTS
 Safe and high-quality care demands reliable teamwork
and effective collaboration, especially in operating
theaters and in intensive care settings.
 Although not fully explored, effective communication
and relationship between surgeons and intensivists/
anesthesiologists improve perioperative outcomes.
 Effective communication, relational coordination,
and team situation awareness influence the surgeon/
intensivist relationship in three different phases of the
multidisciplinary patient-centered approach:
preoperative, intraoperative, and postoperative.
 Communication and nontechnical skills should be
trained (using high-fidelity simulation, didactics,
crisis-resource management) to study team dynamics
and improve teamwork.
interventions to prevent further deterioration. In
this context, patients’ outcome is profoundly
affected by appropriate management. Effective col-
laboration among different professionals is aimed at
patient care, recovery, and rehabilitation. With the
expansion of new medical superspecialist disci-
plines, patients’ care has turned from a holistic
approach to a progressive fragmentation, thus
resulting in errors and impairing outcomes. Effec-
tive teamwork and communication could therefore
address this problem and maintain an integrated
approach to patients’ illnesses [3]. Teamwork refers
to the leadership, decision-making, communica-
tion, and coordination behavior used by multi-
disciplinary team members to provide patient
care. Effective teamwork has been demonstrated
to improve quality-of-care, patient outcome, and
to foster healthier relationships between all profes-
sionals involved [4]. Interprofessional care refers to
actions of healthcare providers with overlapping
expertise working together to achieve a common
goal. From this perspective, interdisciplinarity is
based on sharing roles and responsibilities regardless
&
of the specific individual expertise [5 ]. On the other
side, multidisciplinary or interdisciplinary care are
the terms used when team members work in parallel
maintaining more strict disciplinary boundaries [6].
Team behavior can simultaneously cause and pro-
tect against errors. To understand team performance
and causes underlying active and latent failures [7], it
is important to consider psychology concepts as
decision-making, leadership, team cohesion, team
mental models, and team climate [8]. Besides,
fatigue and nontechnical skills may have a profound
impact on teamwork performances [9,10]. As in the
case of the aviation model, periodical training on
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communication and leadership skills, workload, and
stress management improve teamwork efficiency [11].
Although extensively recognized, healthcare team
training has not been yet uniformly adopted and only
a small number of healthcare providers regularly
undergo specific training [12]. Ineffective communi-
cation is one of the leading causes of medical errors
[13,14], being the casual factor in 82% of adverse
events or close-call reports [15] and considered respon-
sible for 60% of adverse events by the Joint Commis-
sion on Accreditation of Healthcare Organizations.
Different studies have highlighted the importance
of effective communication in the whole surgical care
pathway, especially in operating rooms where mis-
communication is more likely to happen [16,17].
Interaction between members of anesthesia, surgical,
and ICU teams has received less attention than com-
munication between healthcare professionals and
patients or their relatives. Surgeon and anesthesiolo-
gist/intensivist are the key players inside and outside
the operating room, and their communication skills
are essential to achieve patients’ recovery and good
outcome. Interpersonal interactions take advantage of
verbal and nonverbal communication. Although ver-
bal skills are based on honesty in thought and speech,
consistency in expression, and clarity in delivering the
message, facial expressions, body language, and the
ability to listen to others are the cornerstones of
nonverbal communication skills [18]. The entire sur-
gical process (from preoperative assessment to post-
operative care) is affected by poor communication
strategies. Miscommunication is much more present
during preoperative assessment and superficiality
seems to be the main issue. However, uncertain distri-
bution of responsibilities and leadership may contrib-
ute to the emergence of errors. Lack of standardized
communication models, leading to missing or excess
of information, has been related to postoperative
mistakes [19]. Interestingly, most misunderstandings
originate from verbal communication, particularly
when surgeons are involved [20].
SURGEON AND INTENSIVIST:
PERSONALITIES AND STEREOTYPES
Striving to provide the best quality-of-care, surgeons
and anesthesiologists/intensivists have to face differ-
ent gaps between their practice and chances to
improve patients’ outcomes. Beyond limits imposed
by the suboptimal adoption of shared evidence-based
health interventions and guidelines [21], there are
often psychological factors hampering interprofes-
sional communication. Teamwork dynamics are
affected by stereotypes, which are a disruptive psy-
chological state experienced when feeling at risk for
confirming a negative, fixed, and simplified image or
www.co-anesthesiology.com 171
Intensive care and resuscitation
idea of a person, about his/her social identity [22].
The overabused orthopedics–anesthesiologist gag
Patient’s got a broken bone. . .I’ve to fix it, and the
forever-eternal triad coffee–anesthesia–newspaper
(recently replaced by coffee–anesthesia–smartphone)
are simplifications of stereotypes’ role, often influ-
encing team’s dynamics. Although the stereotype of
the abrasive surgeon no longer applies to many mod-
ern professionals, this concept continues to influence
patients’ expectations and surgeons’ interactions
with their colleagues [23]. Fortunately, the image
of surgeon and anesthesiologist/intensivist has
evolved at the same rate of medical progress. The
surgeon’s personality is mainly characterized by deci-
siveness, control, and confidence. The surgical pro-
cedure acquires the dignity of a ‘covenant to cure’,
and surgeons often reject all the actions undermining
this belief (such as requesting the collaboration of
other professionals, losing control over clinical deci-
sions, and proposals on limiting ineffective treat-
ments) [24–26]. This intransigence may play a
confusing factor, both for patients and families and
among acute care team itself. In contrast, anesthesi-
ologists/intensivists perspectives are considered to be
more holistically. Dedicated intensivists for surgical
critically ill patients appear to improve outcomes,
and the reason for this is not well known. However,
intensivist-directed teams may identify and treat
problems in time before irreversible complications
occur [25].
Poor team communication and stereotypes con-
tribute to professionals’ disruptive behavior, a term
used to describe a range of unacceptable clinician
actions, including incivility, bullying, and harassment
[27], which decreases the well-being of clinicians and
undermines the quality-of-care [28]. Intrapersonal,
organizational, and interpersonal factors have been
attributed to its development. Clinicians with under-
lying depression, addiction, fatigue, and burnout
are more prone to act disruptively, especially when
psychological pressures are worsened by adverse work-
ing conditions (personnel and supply shortage, orga-
nizational inefficiencies, long working hours, and
insufficient rest). In particular, surgeons and anes-
thesiologists/intensivists are more likely at risk of
stress and exhaustion being at the forefront of emer-
gency care. Lack of communication, as well as poor
team collaboration and leadership weaknesses, have
been attributed to the interpersonal limitations bring-
ing to behavioral disruption.
SURGEON AND INTENSIVIST: WHO IS THE
LEADER?
Leadership is a multidimensional, complex behavior
that includes effective communication, efficiency,
172 www.co-anesthesiology.com
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decision-making, and resource management skills
[29]. The leader is anyone who influences the activi-
ties of an organized group in its efforts toward goal
setting and achievement, providing a vision for the
future, a direction for change, and a sense of clear
purpose [30]. Surgeon and intensivist/anesthesiolo-
&&
gist share, yield, or compete for leadership [31 ],
influencing teamwork effectiveness. Although
leadership is usually attributed to the surgeon,
intensivists/anesthesiologists are deeply involved
in maintaining the efficiency of the surgical service
and may have a more complete vision of the oper-
ating theater organization, thus bringing a valuable
management perspective. Trauma care and trauma
teams are perfect examples of cross-disciplinary
leadership models [3]. It has been demonstrated
that if emergency physicians and surgeons share
leadership roles by collaborating (cross-disciplin-
ary) care is delivered faster if each physician makes
decisions independently (parallel decision-making)
[29]. Therefore, the leadership cross-disciplinary
model and appropriate task delegation may likely
sort positive effects on the surgeon–intensivist/
anesthesiologist perioperative collaboration.
SURGEON AND INTENSIVIST: HOW TO
COMMUNICATE?
The impact of human factors in surgical patient
safety has been extensively revised, and in particu-
lar, it has been highlighted how quality and effi-
ciency of surgical procedures are contingent on
high-quality communication and shared knowl-
edge, which is challenging to achieve because of
the interdependence, time constraints, and uncer-
&&
tainty of the surgical context [32,33,34 ]. The need
for developing a patient-centered approach for sur-
gical care has contributed to the relational coordina-
tion theory success, which is a mutually reinforcing
process of communicating and relating across areas
of expertise to achieve task integration [35]. The
process by which people acquire information,
understand, and utilize it to comprehend and be
aware of the dynamic situation is often referred to as
situation awareness [36]. In this light, clear, accurate,
and problem-solving communication acquires
strength and impacts on the performance of health-
care professionals, particularly under unexpected
circumstances and time constraints, which charac-
terize surgical and acute care. Studies have demon-
strated that relational coordination is related to
higher quality levels, job satisfaction, work engage-
ment, and surgical outcomes (lower postoperative
pain, lower rate of infections complications, and
shorter hospital length-of-stay) [37]. Good commu-
nication patterns are experienced when each
Volume 33  Number 2  April 2020
 How to communicate between surgeon and intensivist? Misseri et al.
professional perceives to be involved in a shared
challenge and when individual’s expertise is valued
by each member. On the counterpart, bad commu-
nication emerges in case the interdisciplinary team
does not maintain a unitary vision, and when exper-
tise is not valued or given weight in decision-making
[38]. As a result, team members perceive that
patients are receiving inappropriate care.
Communication modes
Formal and informal communications may be
applied in surgeon–intensivist/anesthesiologist
relationship. The former are based on communica-
tion following institutions’ directives (clinical docu-
ments, medical records, morning rounds, checklists,
and team hierarchy), while the latter on personal
contacts excluding preset institutional structures.
Medical records and documents are the primary
formal modes by which team members communi-
cate. Yet, unstructured written communication is
the most common form of interaction in daily prac-
tice, despite being prone to misunderstandings.
Although indispensable for patient care, written
notes (whether article or web-based) are often
unwelcome both for intensivists and for surgeons,
who often perceive them as isolated documents
mandatory by law. Implementation of simple
checklists has contributed to teamwork satisfaction
and effectiveness of handovers for surgical patients.
Electronic medical records are progressively replac-
ing written documentation. Fillable communica-
tion tools to accompany the daily progress notes
could better ensure high compliance and interdisci-
&
plinary work efficiency [39 ]. Morning rounds
may be the only occasion of direct interaction
between the surgeon, intensivist/anesthesiologist,
and patients. They can take place both preopera-
tively and postoperatively and involve trainees and
attendings from the surgical and anesthesia team.
These ‘bedside’ times may promote a multidisciplin-
ary preoperative assessment and set patient-tailored
management strategies and shared postoperative
goals. Informal strategies are mainly based on new
communication technologies, such as text messag-
ing and emails. Even if preferred for their immedi-
acy, some concerns on patients’ health-related data
protection may arise. Face-to-face communication
is usually welcomed by the majority of healthcare
professionals. However, these interactions are
unplanned in most of the cases, especially when
occurring outside the operating room. When asked,
professionals prefer communication with colleagues
with whom they have more familiarity, even if in
some occasions, this hampers good communication
[38].
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THE THREE PHASES OF SURGEON–
INTENSIVIST COMMUNICATION
Effective communication, relational coordination,
and team situation awareness affect the quality of
teamwork in three different phases of the patient-
centered care process (Fig. 1).
Preoperative communication
As surgery has progressed, the function of anesthe-
tists/intensivists has evolved adding to the provision
of optimal perioperative conditions a more invasive
support of vital functions. Leaving the narrowness of
operating room’s workflow, intensivists have gradu-
ally gained the figure of comprehensive perioperative
consultants aiming to a synergistic relationship with
surgeons and other professionals [40]. This has been
implemented with the introduction of Enhanced
Recovery After Surgery (ERAS) bundles, designed to
cover the entire continuum of perioperative patient
care. With the aim to reduce mortality rates, improve
recovery and shorten the length-of-stay after major
surgery, ERAS protocols include a multimodal and
integrated evidence-based approach, including
preoperative risk assessment, surgical procedures,
anesthesia plan, therapies optimization, pain man-
agement, and postoperative goals [41]. Short-term
outcomes and long-term survival are both improved
by increased compliance to ERAS protocols. Preoper-
ative briefings between surgical team members are
essential to discuss and prepare for a given case. The
implementation of surgical safety checklists has
greatly reduced morbidity and mortality [42,43].
Besides, perioperative briefing and debriefing have
improved the team climate and the efficiency of their
work, especially for surgical teams with alternating
members’ composition [44]. Although studies [45,46]
have demonstrated that most differences in percep-
tions of teamwork and communication among team
members exist mostly between surgeons and nurses,
it seems that anesthesiologists perceive larger areas for
improvement and that preoperative communication
across groups could be enhanced. Potential reasons
for suboptimal ratings of preoperative communica-
tion across groups are differing expectations for the
timing or content of interprofessional discussions,
disparate perceptions of team members’ roles, several
organizational barriers. These findings may be used to
promote future research on preoperative communi-
cation and to adopt quality improvement measures to
enhance effective surgical teamwork [47 ].
&
Intraoperative communication
Surgical team members must discuss the plan
of action and establish a shared mental model to
www.co-anesthesiology.com 173
Intensive care and resuscitation
FIGURE 1. Improving communication between surgeons and intensivists/anesthesiologists. Infographics on strategies to
improve communication between surgeons and intensivists/anesthesiologists.
coordinate professionals toward the aimed goal.
Briefing, exchange of reflections, and debriefing
are needed several times during operations
[48,49]. Team’s adaptive capacity may be subjected
to additional stressing factors when different team
members alternate during their shifts, as lack of
knowledge about one another may increase mis-
communications and interruptions during surgical
procedures. For these reasons, leadership and team
coordination are needed. Ethnographic studies have
identified four different communication patterns in
operating theaters, strictly connected to the level of
&&
complexity of surgical procedures [34 ]. However,
more studies are needed to analyze the relationship
between surgeon and anesthesia team. Training,
high-fidelity simulations, and crisis resource
management ensure improved operating room’s
teamwork and communication, as revealed by
a retrospective study showing 18% reduction of
postoperative complications in the annual surgical
mortality of institutions promoting team-training
&
programs [50,51 ].
174 www.co-anesthesiology.com
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Postoperative communication
Postoperative goals-of-care should be discussed
and planned to determine patients’ priorities in a
multidisciplinary way. However, often clinicians
&
perceive barriers to communicate [52 ]. More than
40% of surgeons who routinely perform high-risk
operations report conflict with intensivists and
nurses regarding the goals-of-care for their patients
with poor postoperative outcomes [53], especially
when practicing in a ‘intensivist care model’ ICU
that hinders surgeon’s decision-making autonomy.
Recent evidence suggests that patient-centered
interdisciplinary bedside rounds in ICU provide a
greater efficiency, communication, satisfaction, and
consistent teaching among healthcare providers
[54]. Exclusion of surgery and intensive care resi-
dents (the so-called resident-bypass) from the deci-
sion-making process should be avoided and efforts
are needed to develop their communication skills
and competence [55]. Handovers checklists and
multidisciplinary daily communication tools have
demonstrated to improve effective communication
Volume 33  Number 2  April 2020
 How to communicate between surgeon and intensivist? Misseri et al.
between surgeons and ICU teams [38]. Therefore, an
interprofessional shared decision-making model of
care should be adopted to provide high-quality
&&
treatments [56 ,57].
CONCLUSION
The surgeon–intensivist relationship is essential for
organizational efficiency in operating theaters and
ICU. Different actions should be implemented to
achieve better interprofessional collaboration and
high-quality patient care. Teamwork training
and a patient-centered multidisciplinary approach
may help ensure better communication. Further
research is needed to understand the interpersonal
underlying dynamics influencing patients’ safety
and clinical outcomes.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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Volume 33  Number 2  April 2020