Our aim was to determine if a surgeon's behaviors can encourage or discourage trainees from speaking up when they witness a surgical mistake.

A randomized clinical trial in which medical students (n = 55) were randomly assigned to an “encouraged” (n = 28) or “discouraged” (n = 27) group. Participants underwent personality tests to assess decision-making styles, and were then trained on basic tasks (“burn” then “cut”) on a laparoscopic surgery simulator. After randomization, students assisted at a simulated laparoscopic salpingectomy. The senior surgeon used either an “encourage” script (eg, “Your opinion is important.”) or a “discourage” script (eg, “Do what I say. Save questions for next time.”). Otherwise, the surgery was conducted identically. Subsequently, a surgical mistake was made by the senior surgeon when he instructed students to cut without burning. Students were considered to have spoken up if they questioned the instruction and did not cut. Potential personality bias was assessed with two validated personality tests before simulation. Data were processed with Mann-Whitney and Fisher exact tests.

The students in the encouraged group were significantly more likely to speak up (23 of 28 [82%] vs 8 of 27 [30%]; p < 0.001). There was no statistically significant difference between the two groups in personality traits, student training level (p = 1.0), or sex (p = 0.53).

A discouraging environment decreases the frequency with which trainees speak up when witnessing a surgical error. The senior surgeon plays an important role in improving intraoperative communication between junior and senior clinicians and can enhance patient safety.