Volume 70, Issue 10 p. 1119-1129
Original Article
Free Access

Power and conflict: the effect of a superior's interpersonal behaviour on trainees’ ability to challenge authority during a simulated airway emergency

Z. Friedman

Corresponding Author

Z. Friedman

Associate Professor and Staff Anesthesiologist

Mount Sinai Hospital, Toronto, Ontario, Canada

Correspondence to: Z. Friedman

Email: [email protected]

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M. A. Hayter

M. A. Hayter

Assistant Professor and Staff Anesthesiologist

St Michael's Hospital, Toronto, Ontario, Canada

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T. C. Everett

T. C. Everett

Assistant Professor and Staff Anesthesiologist

The Hospital for Sick Children, Toronto, Ontario, Canada

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C. T. Matava

C. T. Matava

Assistant Professor and Staff Anesthesiologist

The Hospital for Sick Children, Toronto, Ontario, Canada

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L. M. K. Noble

L. M. K. Noble

Anesthesia Assistant and Respiratory Therapist

Mount Sinai Hospital, Toronto, Ontario, Canada

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M. D. Bould

M. D. Bould

Associate Professor and Staff Anesthesiologist

Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada

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First published: 21 August 2015
Citations: 49

Presented in part at the Canadian Anesthesiologists' Society Annual Meeting, St John's, NF, Canada, June 2014.

This article is accompanied by an editorial by A. Palanisamy and B. Jenkins, Anaesthesia 2015; 70: 1110–3.


You can respond to this article at http://www.anaesthesiacorrespondence.com


A key factor that may contribute to communication failures is status asymmetry between team members. We examined the effect of a consultant anaesthetist's interpersonal behaviour on trainees’ ability to effectively challenge clearly incorrect clinical decisions. Thirty-four trainees were recruited to participate in a video-recorded scenario of an airway crisis. They were randomised to a group in which a confederate consultant anaesthetist's interpersonal behaviour was scripted to recreate either a strict/exclusive or an open/inclusive communication dynamic. The scenario allowed trainees four opportunities to challenge clearly wrong decisions. Performances were scored using the modified Advocacy-Inquiry Score. The highest median (IQR [range]) score was 3.0 (2.2–4.0 [1.0–5.0]) in the exclusive communication group, and 3.5 (3.0–4.5 [2.5–6.0]) in the inclusive communication group (p = 0.06). The study did not show a significant effect of consultant behaviour on trainees’ ability to challenge their superior. It did demonstrate trainees’ inability to challenge their seniors effectively, resulting in critical communication gaps.


Effective communication is a key part of efficient teamwork. It becomes crucial during management of life-threatening crisis, and its breakdown may pose a severe threat to patient safety. A study that examined operating theatre communication categorised 30% of all communication events as failures, a third of which threatened patient safety 1. A Joint Commission on Accreditation of Healthcare Organisations report highlighted the causative role of communication breakdown in the occurrence of sentinel events, resulting in death or permanent loss of function 2. It identified communication problems as root causes in 62–82% of adverse events.

A key dynamic that exists in healthcare and may contribute to communication failures is ‘status asymmetry’, or authority gradients between team members. Kohn et al. described it in their Institute of Medicine report To Err is Human 3. Its importance in human performance and patient safety has also been emphasised in Miller's Anesthesia 4.

Although present in some form in many medical teams including nurse-physician encounters, an authority gradient may have its most profound effect during encounters between consultant and trainee physicians as the consultant has a direct influence on a trainee's career. Trainees, who in many cases spend short rotations in different centres during their training, perceive themselves as transient care providers, and are reluctant to challenge incorrect decisions made by a superior 5, 6. Patient safety may be compromised when this type of subordinate behaviour occurs in the context of a medical crisis 7.

Whereas there is a significant body of evidence on factors that affect speaking-up behaviour in other domains, this aspect of research is still fairly new within healthcare. This gap is reflected in a recent editorial, which asserts that simulation publications overlook sociological factors such as hierarchy, power relations and professional identity that are now understood to affect communication and teamwork 8. Not all the factors that affect communication when authority gradients are present are subject to change, but a recent review identified interpersonal behaviour of superiors and the training of trainees as factors that are amenable to educational intervention 9. Interpersonal communication skills have been identified as core competencies by the Accreditation Council for Graduate Medical Education in the USA 10, the Canadian Royal College of Physicians and Surgeons of Canada CanMEDS physician competency framework (Communicator and Collaborator roles) 11, and the General Medical Council's guidelines for Good Medical Practice in the UK 12.

Failure to challenge authority effectively is a real problem that can contribute to preventable mortality. Fioratou et al. examined the highly publicised Elaine Bromiley case, in which a young woman died after induction of anaesthesia for a minor procedure that turned into a ‘can't intubate, can't ventilate’ crisis 13. According to the formal inquiry, several team members recognised the gravity of the situation but either did not speak up or only acted indirectly 14, with the result that team leaders ignored information from the team that could have been life-saving.

In this study, we examined the effect of the superior's interpersonal behaviour on trainees’ ability to speak up when a clear clinical mistake is made. Previous simulation studies have used intentionally ambiguous situations in which the given commands were relatively wrong 15. In a previous study, we found that trainees were unable to challenge an unethical decision by their superior 6. In this study, we sought to reduce ambiguity by creating a series of clinical decisions made by the superior that were clearly incorrect, therefore enabling us to examine the effect of the superior's interpersonal behaviour.

We hypothesised that a strict exclusive behaviour by the consultant anaesthetist would have a negative effect on trainees’ ability to challenge clearly incorrect clinical decisions made during a life-threatening airway crisis. We tested this hypothesis by designing a high-fidelity simulation session with a ‘can't-intubate-can't-ventilate’ crisis scenario that is grossly and clearly mismanaged by the consultant anaesthetist.


Data collection was performed at the Mount Sinai Department of Anesthesia, University of Toronto, Canada, over a period of 18 months starting July 2011. Following approval by the Mount Sinai Hospital Research Ethics Board), and the university postgraduate committee, second-year anaesthesia trainees were recruited to participate in a simulation session. Written informed consent was obtained from each trainee before participation.

Residents were randomly assigned using a computer-generated list to participate in a simulated scenario with a consultant anaesthetist whose interpersonal behaviour was scripted to either recreate a strict and exclusive communication dynamic or an open inclusive communication dynamic with a minimal hierarchy effect. The study took place in a simulation laboratory with an operating theatre setting that included a high-fidelity manikin, an anaesthesia machine and all standard operating theatre monitors.

We used deliberate deception in this study: the fact that the consultant anaesthetist (played by a 48-year-old Caucasian male anaesthetist with whom the trainees had not worked before the study) was a confederate was not disclosed to the trainees until the debriefing at the end of the simulation session. Residents were told that the consultant anaesthetist was also a subject in the study, and that the purpose of the study was to compare behaviour in simulated settings to behaviour in clinical settings. This deception was explicitly described in the research ethics submission. The third team member role in the simulation was a circulating nurse, also played by a confederate. The roles of the consultant anaesthetist and circulating nurse were precisely scripted to allow them to respond to a range of questions and challenges by the trainee (see Appendix 1).

Sociological fidelity is a relatively new concept in medical simulation, with very few publications describing how to recreate reliably this aspect of the communication dynamic 8. The initial script and scenario were determined by consensus of the investigators based on our previous work and on the concept of Leader Inclusiveness 16. This concept has been described as the superior's ability to be supportive and empathic, and to respond quickly to messages. The behaviour and reactions of the confederates in each group were then developed and tested during several pilot scenarios that were not included in the final data analysis (see Appendix 2). These included both verbal (style of introduction, discussion with subjects before the scenario and responsiveness during the scenario) and non-verbal (eye contact, facial affect) aspects. The ability to differentiate and identify group allocation (strict exclusive versus open inclusive communication) was assessed by an independent video rater during the pilot scenarios. To avoid bias, confederate roles were played by the same individuals in all the scenarios.

At the end of each session, trainees were debriefed and discussed the scenario. The fact that the consultant anaesthetist was a confederate was disclosed, and trainees were again given the option to withdraw from the study. Their opinion on the management of the case by the superior was also elicited. At the end of the debriefing, trainees were asked not to discuss the scenario with their peers.

Each simulation session started with a pre-briefing for the participating trainee and the confederate consultant anaesthetist. They were introduced to the simulation setting and given the patient's history. The case was described as a routine elective laparoscopic assisted vaginal hysterectomy for a 69-year-old female with mild obesity, hypertension not requiring medication, and a long-standing history of sleep apnoea.

The trainee and consultant were then left alone for 3 min while the simulation laboratory was being prepared. The purpose of this encounter was to establish the behaviour pattern of the confederate consultant and the communication dynamic of the scenario according to group allocation (strict exclusive versus open inclusive communication dynamic). The confederate consultant was either approachable and talkative in the open communication dynamic group or silently checking messages on his phone and not engaging in conversation with the trainees in the strict exclusive behaviour dynamic group.

The consultant was then called in to start the case, and after 5 min the trainee was called in to help with management. Upon entering the room, the trainee was told by the consultant that the induction had started and that a neuromuscular blocking agent was given 90 s previously. The trainee was then asked to assist the consultant during the intubation, which would take place in 1 min. The case then progressed to a ‘can't-intubate-can't-ventilate’ scenario as described in the script (Appendix 1). Residents had several opportunities to challenge the consultant's management during each phase as the scenario unfolded:
  1. During the first minute of mask ventilation preceding the intubation, there was no chest rise and no end-tidal CO2 trace on the monitor. The consultant anaesthetist did not recognise this and continued with non-effective ventilation before proceeding with the intubation.
  2. The first intubation attempt was declared to reveal a grade-4 Cormack–Lehane laryngoscopic view. No further action was taken by the consultant in reaction to this. Laryngoscopy was attempted for 30 s, followed by 40 s of ineffective ventilation attempts (no chest rise, no end-tidal CO2 trace on the monitor). At the end of this 70-s period, the oxygen saturation dropped to 89%.
  3. A second attempt was performed over the next 30 s. This attempt was an exact repetition of the first intubation attempt, followed by 40 s of ineffective ventilation with no changes to management. At the end of the 70-s period, oxygen saturation dropped to 61%. Heart rate and blood pressure also dropped.
  4. Two more (a third and a fourth) identical intubation attempts were performed in exactly the same manner. The scenario was terminated 70 s after the fourth intubation attempt. The patient's vital signs rapidly deteriorated to severe bradycardia and hypotension with low oxygen saturation.

All sessions were video-recorded. They were later assessed in random order by two independent raters blinded to group allocation and unfamiliar with the subjects, using the modified advocacy-inquiry score 6, 17 (mAIS, Appendix 3).

Before the assessment, raters were trained by one of the authors (ZF) on the use of the mAIS: after a description of the scale and its anchors, video-recorded scenarios identical to that used in the study (but not included in the analysis) were first rated independently. The ratings were then discussed to ensure consistency.

All analyses were carried out using The SAS System for Windows v.9.3 (Cary, NC, USA). Individual challenging opportunities were treated as the unit of measurement in assessing agreement between raters on presence/absence of attempts per opportunity and individual mAIS scores. Clustering and relatedness of observations taken on the same individual across sessions were ignored to allow for assessments of reliability.

Intra-class correlation coefficients (ICC) were used to assess the degree of agreement across raters on the mAIS score. The inter-rater reliability of the mAIS scores among raters was graded according to the guidelines suggested by Landis and Koch 18. Scores were averaged between raters to yield a single mAIS score (minimal and maximal score 1 and 6, respectively) per subject per challenge.

The primary outcome was a comparison of the best mAIS scores of the four challenge opportunities between the groups, as this was deemed to be the most significant parameter to represent an effective challenge and the most likely one to change the consultant anaesthetist's management.

The scenarios were assessed by a third independent blinded rater for an observable difference in the consultant anaesthetist's behaviour pattern between the groups.

Targeting a large effect size is generally considered appropriate for the purposes of sample size calculation in the fields of psychology and education research 19, 20. Our sample size calculation was based on our primary outcome variable. Assuming a two-tailed alpha of 0.05, a power of 80% and a Cohen's d effect size of 1, we determined that we needed 17 trainees in each group 21.


Thirty-four second-year trainees completed the study. There were five female trainees and 12 male trainees in the open inclusive group, vs six females and 11 males in the strict exclusive communication group. All of the trainees had comparable previous experience participating in simulation.

The inter-rater reliability of the mAIS scores among raters (ICC = 0.92 (95% CI 0.88–0.94)) suggests an excellent degree of agreement across raters. The median (IQR [range]) of the maximal mAIS (our primary outcome) across all challenging opportunities and averaged out across raters was 3.0 (2.2–4.0 [1.0–5.0]) in the strict exclusive group and 3.5 (3.0–4.5 [2.5–6.0]) in the open inclusive group. This difference was not significant (p = 0.06, Fig. 1).

Details are in the caption following the image
Maximal mAIS scores for challenges to authority. Horizontal line = median; box = IQR; whiskers = 1.5 IQR; dots = outliers.

The third independent rater correctly identified the group allocation (strict uncooperative versus open dynamic) in 100% of the video-recorded sessions. During the debriefings and structured interviews following each session, trainees uniformly stated they knew the crisis was mismanaged and that the patient's safety was compromised.

Repeating increasingly worsening vital signs to the attending consultant was the almost unanimous oblique challenge made by the trainees throughout the scenario. Following the first intubation attempt that was declared as a grade-4 view, reactions mostly ranged between no verbal reaction at all (equivalent to an mAIS of 1) to “did you want me to call the Anaesthesia Assistant for a GlideScope?” (mAIS of 3), without initiating a discussion or advocating an alternative management plan. As the situation deteriorated with further intubation attempts, the quality of challenges tended to improve slightly, especially following no initial challenge, and in most cases challenges reached their maximal score during the third and fourth intubation attempts.

The highest mAIS score of 6 was only given once. The resident kept his hands on the mask and prevented the attending consultant from trying to intubate again when the patient's vital signs were deteriorating, while saying “No, I really think we should bag her up a little more”. Other strong challenges, which include crisp advocacy-inquiry, were used to challenge in a few cases. The resident in that case used very clear language: “I think we should stop, you haven't changed anything. We should stop and get the difficult airway cart. Nurse, please call for help”. Most subjects offered the use of an adjunct at some point. When suggestions were answered by a false statement “This is a grade-4 view, a laryngeal mask/GlideScope/bougie would not help us”, none of the subjects challenged it.

During the debriefing, none of the subjects were obviously upset about the deception that was part of the scenario. They all felt this was a very helpful experience: “I definitely think having participated in this will help increase my awareness. The fact is that subtle communication just doesn't work in this kind of situation”.


Overall, there was no compelling evidence to suggest a significant difference in performance between the two groups. The interpersonal behaviour of the consultant anaesthetist and the resulting communication dynamic during the simulated airway crisis did not have a significant effect on trainees’ ability to challenge the consultant anaesthetist's management.

An important finding of the study was that trainees were unable to challenge their superior's clearly wrong clinical decisions effectively during a life-threatening crisis. The low mAIS scores reflected an inability to challenge the superior's wrong decisions effectively in both groups. When challenges were made, their quality was mostly poor. The median challenge score was equivalent to an isolated inquiry or advocacy statement, with no repetition of the challenge or initiation of further discussion, no use of crisp advocacy/inquiry and no attempts to take over management of the case. In the setting of a crisis, this kind of oblique communication is highly unlikely to result in effective communication. The generalisability of this result is obviously limited by the unique setting of a simulation and the unfamiliarity of the superior to the trainees. Having said that, the inability of trainees to intervene in a setting of a black-and-white scenario with repeated, obvious and life-threatening mistakes is alarming, and this behaviour could translate into ‘real-life’ errors of management.

These current results are a direct continuation of those demonstrated in a previous study by our group, which investigated trainees’ behaviour when faced with an unethical decision of giving blood to a Jehovah's Witness 6. These results were challenged by correspondents who argued that the scenario did not constitute a clearly unethical decision, and that this may have been the cause of the poor quality of the challenges made. We therefore used a very ‘black-and-white’ clinical scenario, scripted to create a clearly wrong chain of decisions by the consultant during an escalating airway crisis. It was designed to avoid reliance on content knowledge using a very basic difficult airway algorithm script.

Second-year anaesthesia trainees at our institution attend a difficult airway course that includes difficult airway simulations before starting their second year of residency, and they were therefore very familiar with the difficult airway algorithm. Furthermore, the actions expected from the trainees during the scenario were very basic. They were expected to stop repeated intubation attempts, offer alternatives and call for help. The authors felt that this script would create a very clear-cut scenario in which the trainees would readily identify the mistakes in management made by the consultant.

We used the mAIS scores as our primary outcome. The mAIS is a modification of the Advocacy-Inquiry method, which includes five scoring levels 17. It assigns scores to the language used by subjects when challenging a superior. The more effective the challenge is (incorporating both advocacy and inquiry in a crisp and clear manner), the higher the score. The previously described modification 6 adds a sixth level in the case of a subject attempting to take over management of the case (e.g. physically blocking the consultant anaesthetist from intubating again, bypassing him by initiating a ‘code blue’ or calling in a second consultant anaesthetist despite objection). Previous research supports the validity of the modified scale by demonstrating an improved score in trainees who received specific instruction on challenging authority, and in trainees with increased experience (higher residency year) 6, 17. We also used deception in order to achieve ‘sociological fidelity’ 8 that replicated the communication dynamic in ‘real life’ and elicited natural responses from the subjects while controlling differences in the consultant's behaviour between the two study groups.

The concept of deception in simulation warrants further comment, as it is a controversial issue that carries the potential for learners to experience shame and humiliation. Robert et al. argued that this is especially true in scenarios of challenging a wrong decision, since learners find that that have the knowledge to treat a problem but are unable to speak up to authority, even when patient safety is involved. In their opinion, the former is an inadequacy in knowledge, whereas the latter may be considered an inadequacy in character 22.

We strongly believe that not being able to challenge authority stems from a lack of appropriate conflict management training. This is evident by the prevalent failure to challenge in our study and previous studies, implying that this is a systematic problem and not a character failure. During the debriefing we made it very clear to the learners that we put them in a very difficult situation with which, in our opinion, they were not equipped to deal, and that all their colleagues had similar problems challenging authority. There followed an open discussion regarding how the learners felt regarding the deception. The residents unanimously agreed that this was a problem and a gap in their training, and none of them showed any signs of being upset by the deception. Some residents mentioned previous cases with similar conflicts, and stated that the tools given to them during the scenario and debriefing would be extremely helpful in the future. None of them requested to be removed from the study, and they all had the benefit of ongoing support from their instructors and consultants as well as their fellow learners. Support was readily available if such problems arose during the debriefing. It might be said that learners did not want to appear vulnerable, and may have been hiding any distress they might have felt. This, however, could be said for any simulation scenario, and from our experience it is evident that learners do not hesitate to express how stressful the experience was.

Could the teaching goals have been achieved if the trainees were warned about the poor management of the consultant? We believe that we could not view the results as unbiased indicators of the problem if deception was not a part of the scenario. Both the severity and extent of the problem, as well as the effectiveness of a teaching intervention, could not be assessed if the natural hierarchy were not preserved.

A previous study by Pian-Smith et al. was one of the first to use a simulation scenario that incorporated challenge opportunities 17. This and other studies intentionally included ambiguous scenarios that were designed to be ‘grey’ and dependent on relatively advanced content knowledge. A recent review that focused on speaking-up behaviour highlighted the ambiguity or clarity of the clinical situation as one of the factors influencing the decision to speak up 9. Recent literature emphasises the importance of creating scenarios without the confounding influence of ambiguity on a subordinate's willingness to challenge 15.

Despite the clear deviation from basic airway management guidelines by the senior physician, most trainees were unable to challenge effectively or advocate on the patient's behalf even when faced with a clearly wrong chain of decisions directly endangering patient safety. This happened even though (as confirmed during the debriefings and structured interview following each session) trainees uniformly declared they had no doubt the crisis was mismanaged by the consultant and the patient's safety was severely compromised as a result. In many cases, team members may feel less responsible for their own actions and will view themselves as just an ‘agent’ of their leader. The influence of issues such as desire for promotion, approval and appropriate respect for seniority makes it difficult to challenge a superior.

This type of communication problem has been previously recognised in the aviation industry in which, like medicine, there is a strict hierarchical structure. Aircraft crashes have been linked to inability of junior crew members to challenge their seniors’ decision effectively 23. In his bestselling book Outliers, Malcolm Gladwell links the influence of the Korean inherent strict cultural hierarchy and inability to contradict a superior to the spate of plane crashes involving the Korean airlines 24. Studies that traced 70% of aircraft accidents to communication failures led to the genesis of ‘Cockpit/Crisis Resource Management’ (CRM) training 25 with the encouragement of training crews to ‘speak up’ when safety concerns arose 26.‎

When a matter of patient safety is involved, it should be clear that it is the trainee's responsibility to express his concerns clearly and the supervisor's responsibility to acknowledge and address them. This practice has been a part of aviation training for many years, in the form of the ‘Two challenge rule’ 14. When a junior team member is concerned that the aircraft's safety is in danger, he must challenge the senior pilot twice as necessary. If ignored, he is then authorised to take over control of the aircraft. In our study, equivalent actions would be calling for help from a second physician, involving the surgeon or calling a code blue. Future studies will examine the effect of a teaching intervention targeting this educational gap on this behaviour pattern.

Interestingly, a study looking at cross-cultural perceived barriers in challenging authority by trainees found no difference between the more rigid hierarchical Japanese residency programme trainees and US trainees in terms of challenging their seniors 5. The authors hypothesise that professional cultures override the national culture when it comes to this specific communication aspect. In other words, hierarchy is so dominant in medical culture that it overcomes even national cultural differences in the ability to challenge authority. A similar phenomenon might explain the negative results of our study. Previous exposure to the effects of hierarchy during their career and the organisational and professional culture within which they function may have overcome any effect that the interpersonal behaviours of the superior might have had.

There are other possible explanations for the counterintuitive lack of effect of the consultant's behaviour on the trainees' ability to challenge a clearly wrong clinical decision. Although raters were able to differentiate between the two behaviour patterns in 100% of cases, it is possible that this difference in the superior's scripted behaviour was not perceived by the trainees and thus did not affect their ability to challenge. It is also possible that trainees lack the training required for making the difficult decision of challenging a superior in a system that is deeply hierarchical, regardless of the communication dynamic. Although they are all exposed to simulation and crisis management training, dealing with conflict in general, and specifically when a hierarchy gradient exists, is most likely not to be adequately addressed.

There are several limitations to this study. As previously mentioned, we did not find specific frameworks in psychology or sociology that could guide us in scripting the roles. As a result, the intended difference in the superior's behaviour between the two scenarios may have not been recreated in the simulation, failing to trigger a difference in the subjects’ reaction between the two groups. As with all simulation laboratory studies, there may be a difference between behaviour in the laboratory and in real life. For instance, lack of a CO2 trace and chest rise during the first challenge opportunity may have been attributed by trainees to simulation artefacts.

As discussed, we tried to make the scenario independent of knowledge base by making the case a clear deviation from the airway algorithm. Despite this, knowledge-based mistakes regarding the difficult airway algorithm were still possible, and may affect interpretation of the study result. We chose second-year trainees as subjects since the power gradient is very significant in their case. This was done so that the effect of the superior's behaviour would be noticeable; however, it is possible that the effect of the power gradient was too strong for these junior trainees to be modified by the changes in their superior's attitude. Finally, there was a slight gender difference between the groups that may have affected results.

The best mAIS from four different challenging opportunities was used for analysis. Averaging the scores may have produced different results; however, we felt that the strongest challenge was the most clinically relevant outcome, and the most likely to prevail over any other weaker challenges in a real clinical setting.

Relationship with superiors and the personality of subordinates are important factors in both challenging and not challenging authority 4, 7. It is possible that the results would have been different with a different senior anaesthetist, but other studies show similarly poor performance in other contexts, so this seems unlikely.

This study did not show an effect of a strict exclusive interpersonal behaviour by the consultant anaesthetist on trainees’ ability to challenge a wrong decision. The study did demonstrate important gaps in communication during a simulated crisis, resulting in repeated clinical mistakes and deviations from the difficult airway algorithm and putting patient safety at risk. Residents in many programmes are not taught the proper tools to challenge authority efficiently during a crisis. This educational gap may adversely affect communication during crisis, and may have significant implications that need to be addressed. This would require further research and possibly changes to the residency programme curriculum to include effective communication strategies, including advocacy-inquiry type or ‘speak-up skills’ that can be utilised in a crisis.

Previous qualitative research by our group 6 has identified that trainees are often reluctant to ‘speak up’ and challenge authority in the operating theatre owing to concerns that there will be negative repercussions on their own career if they are seen to be contradicting their consultants. Some participants said that these concerns sometimes prevented speaking up even when they felt that patient care was compromised 6. In anaesthesia, issues of conflict and hierarchy must obviously be considered within the healthcare context: although trainees are learners and junior to consultants in the operating theatre, they are also physicians with responsibility for the safety of the patient. This should always have primacy, but issues of hierarchy and power relations can create tensions that result in poor team behaviours. It is the responsibility of those with power in the peri-operative hierarchy to create a culture where juniors feel valued and are encouraged to speak up to contribute to decision-making. They should not have to tolerate bullying and undermining actions by a superior.


We would like to thank Ms. Lisa Satterthwaite RPN, Shunne Leung, Finch Taylor and the staff of the University of Toronto Surgical Skills Centre and the SimSinai Centre at Mount Sinai Hospital, 600 University Avenue, Toronto M5G1X5, Ontario, Canada for their help and support in this project.

    Competing interests

    Support for this study was provided through a Department of Anesthesia, University of Toronto, Research Merit Award. All authors report no competing interests.

    Appendix 1

    Scenario plan and scripting

    Phase Time Open inclusive communication Strict exclusive communication
    Briefing: Resident and confederate anaesthetist are briefed on the scenario and receive consult form to read in waiting room. They are then left in the waiting area. Consultant is taken to the operating theatre first. Resident walks into theatre to find initial phase 3 min

    Consult has been carried out in the pre-admission facility. Details:

    • ‘65-year old for laparoscopic assisted vaginal hysterectomy’
    • Long-standing history of ‘obstructive sleep apnea on CPAP’

    Introductions: start of scenario; trainee sent to theatre to assist consultant anaesthetist; enters theatre; introductions 30 s
    • Thank you for coming to help, I am (first, last name). What is your name?
    • Consultant is just injecting 50 mg rocuronium
    • Are you the trainee? What's your name?” (no introductions)
    • Consultant is just injecting 50 mg rocuronium
    HR 72 bpm, BP 118/70 mmHg, SpO2 97%

    Information transfer

    Challenge opportunity 1

    (Trainee should point out lack of CO2 trace. Suggest ways for optimising ventilation)

    60 s
    • Consultant anaesthetist to trainee: “This is planned to be a standard laparoscopic hysterectomy. I have just given 150 μg fentanyl, 200 mg propofol and 50 mg rocuronium. I am almost ready to intubate
    • Consultant anaesthetist attempting to ventilate with oral airway already in. No CO2 tracing visible – saturation drifts down to 95% (60 s)
    • Consultant anaesthetist to trainee: “I've already started the induction so I'll manage this
    • Consultant anaesthetist attempting to ventilate with oral airway already in. No CO2 tracing visible – saturation drifts down to 95% (60 s)
    HR 75 bpm, BP 122/70 mmHg, SpO2 95%

    First attempt to intubate

    Challenge opportunity 2

    (Trainee should suggest laryngeal mask, ask for more equipment if grade 4 view)

    70 s
    • Well let's just proceed to intubate
    • Consultant anaesthetist attempts to intubate with a MAC 3 blade, styleted tracheal tube (30 s)
    • Wow, it's a grade-4 view, I really can't see anything
    • Comes out tries to ventilate but still not able to ventilate (40 s)
    • Without saying anything attempts to intubate with a MAC 3 blade and a styleted tracheal tube. (30 s)
    • Consultant anaesthetist says: “Damn I can't see anything
    • Tries briefly to ventilate again unsuccessfully (40 s)
    HR 88 bpm, BP 165/90, SpO2 89

    Second attempt to intubate

    Challenge opportunity 3

    (Should begin to call for help, suggest laryngeal mask again, ask for the difficult airway cart, consider need for surgical airway)

    70 s
    • Consultant anaesthetist anaesthesia to trainee: “The patient seems to be a bit more difficult than anticipated
    • Tries to intubate, fails. (30 s).
    • Consultant anaesthetist anaesthesia to trainee: “Still a grade-4 view
    • Tries ventilating again, fails (40 s)
    • Patient continues to desaturate, SpO2 now 80, Pulse 60 bpm
    • Tries to intubate, fails. (30 s)
    • Consultant anaesthetist says: “Still can't see a damn thing
    • Tries ventilating again, fails (40 s)
    HR 60 bpm, BP 165/90 mmHg, SpO2 61%

    Third attempt to intubate

    Challenge opportunity 4

    (Emergency cricothyroidotomy should be performed, nurse should be told to get help, ‘code blue’ called, no further intubation attempts should be allowed)

    70 s
    • Consultant anaesthetist to trainee: “Resident X please pass me the MAC-3 blade again. We need to secure this airway
    • Tries to intubate, fails (30 s)
    • Tries ventilating, fails (40 s)
    • Consultant anaesthetist to trainee: “Quickly, pass me the MAC-3 blade again
    • Tries to intubate, fails (30 s)
    • Tries ventilating, fails (40 s)
    HR 40 bpm, BP 90/40, SpO2 55

    Fourth attempt to intubate

    (Emergency cricothyroidotomy should be performed, nurse should be told to get help, ‘code blue’ called, no further intubation attempts should be allowed)

    30 s
    • Tries to intubate, fails (30 s)
    • Tries to intubate, fails (30 s)

    End scenario at the end of timeline or:

    • If emergency cricothyroidotomy performed
    • If trainee attempts physically to take over case
    • If trainee leaves the room

    Potential branching points and scripted responses:

    • Trainee proposes laryngeal mask/bougie/GlideScope. Response: “A laryngeal mask/bougie/GlideScope is useless with a grade-4 view when you can't ventilate” (false statement). If suggested again: gets equipment but perseveres with the MAC-3 blade.
    • Trainee challenges to call for help. Response: “We have two anaesthetists in here already, another person would only be in the way” (false statement).
    • Trainee challenges to get the difficult airway cart. Response: “We don't need extra equipment in this situation” (false statement). If trainee insists: equipment is called for but the consultant perseveres with the MAC-3 blade.
    • Trainee challenges to perform a surgical airway at the first two challenges nurse will go get the kit. If asks for the kit on the third challenge then present the trainee with the kit. Response: “I think if I try with the MAC-3 blade one more time it should work. We don't need a surgical airway yet” (false statement)

    Debriefing 15 Trainee is told that the consultant anaesthetist is a confederate. Structured debriefing. Discussion on effectively challenging a superior colleague.

    Appendix 2

    Attending anaesthetist scripted behaviour descriptors

    Open inclusive communication Strict exclusive communication
    Introduction style Introduces self by first name and surname Introduces self as ‘Dr. surname’
    Discussion before scenario Pleasant exchanges; asks about trainee's background Limited to short or no exchanges; does not voluntarily interact with trainees
    Communication with participants during scenario Responsive to trainee input and participation Responds with short comments; assertiveness and suggestions from trainee not accepted

    Appendix 3

    Modified advocacy-inquiry score

    Type of language used to challenge Score Example
    Say nothing 1  
    Say something oblique, obtuse 2 Saturation is 88%
    Inquire about the management plan 3 Do you think we should get a laryngeal mask?”
    Advocate for a backup plan I think we should get the difficult airway cart
    Advocate OR inquire repeatedly, with initiation of discussion 4 Do you want to try a GlideScope? We should have it available in case we can't intubate with a grade-4 view.”
    Use crisp advocacy-inquiry 5 Dr. Smith, we have a grade-4 view and two failed intubation attempts). I'm concerned that this might prove to be a ‘can't intubate can't ventilate’ scenario and we have no alternatives. Would you agree we need a backup plan?
    Attempts to actively take over case, directly calls for adjuncts, bypasses consultant and calls for help, stops consultant from trying to intubate again 6 Attempts to dismiss consultant from position, physically blocks consultant from intubating and calls in second anaesthetist