Surgical Education

The extent of surgical training given to undergraduates is variable and the decisions taken on the adequacy of the amount to be delivered are often made using little evidence. Therefore, these decisions are vulnerable to bias. Arbitrary coherence is a recently recognized behavior that can be induced by influencing subjects to anchor their answers to a series of questions to an unrelated anchor. We set out to assess the impact of arbitrary numerical anchors on answers given to questions concerning surgical training. DESIGN: Prospective Anchoring Study. SETTING: Nonclinical environment. PARTICIPANTS: A group of 41 fourth year medical students.

The SCORE curriculum defines surgical operations/procedures that residents are expected to be competent with by the end of the residency. The purpose of this study was to conduct a gap analysis to determine how well the operative experience in a general surgery residency program approximates the expectations of the SCORE curriculum, especially regarding those procedures considered essential to general surgical training. Final ACGME resident operative experience reports of recent Northwestern University general surgery program graduates (n = 15) were compared with the specific procedures and procedure levels (ie, Essential-Common, Essential-Uncommon, Complex) defined in the SCORE curriculum. The average numbers of individual SCORE procedures and procedures per SCORE procedure level performed per resident were summarized using descriptive statistics. During their 5 years of training general surgery residents logged a mean of 1025.7 (SD 152.9) primary procedures per resident. We were able to match 87.1% of these ACGME logged procedures with specific procedures identified in the SCORE curriculum. On average, of the Essential-common procedures, 23 (35%) were performed >10 times and 35 (53%) were performed >five times. Conversely, the number of Essential-uncommon and Complex procedures performed >five times were 3 (5%) and 10 (7%), respectively. Several procedures identified in the SCORE curriculum were performed at very low frequency during residency training. This experience suggests that leadership at SCORE and the ACGME need to make the curriculum and logging system compatible and that surgical residents need to be better educated with regards to case logging. Despite these issues, important differences appeared to exist between actual resident operative experiences and expectations set by the SCORE curriculum. Based on these finding we advocate that similar gap analyses be performed at other surgical residency training programs to identify discrepancies between program experience and SCORE curriculum expectations.

Optimal team performance in the operating room (OR) requires a combination of interactions among OR professionals and adherence to clinical guidelines. Theoretically, it is possible that OR teams could communicate very well but fail to follow acceptable standards of patient care and vice versa. OR simulations offer an ideal research environment to study this relationship. The goal of this study was to determine the relationship between ratings of OR teamwork and communication with adherence to patient care guidelines in a simulated scenarios of malignant hyperthermia (MH). An interprofessional research team (2 anesthesiologists, 1 surgeon, an OR nurse, and a social scientist) reviewed videos of 5 intraoperative teams managing a simulated patient who manifested MH while undergoing general anesthesia for an epigastric herniorraphy in a high-fidelity, in situ OR. Participant teams consisted of 2 residents from anesthesiology, 1 from surgery, 1 OR nurse, and 1 certified surgical technician. Teamwork and communication were assessed with 4 published tools: Anesthesiologists' Non-Technical Skills (ANTS), Scrub Practitioners List of Intra-operative Non-Technical Skills (SPLINTS), Non-Technical Skills for Surgeons (NOTSS), and Objective Teamwork Assessment System (OTAS). We developed an evidence-based MH checklist to assess overall patient care. Interrater agreement for teamwork tools was moderate. Average rater agreement was 0.51 For ANTS, 0.67 for SPLINTS, 0.51 for NOTSS, and 0.70 for OTAS. Observer agreement for the MH checklist was high (0.88). Correlations between teamwork and MH checklist were not significant. Teams were different in percent of the MH actions taken (range, 50-91%; P = .006). In this pilot study, intraoperative teamwork and communication were not related to overall patient care management. Separating nontechnical and technical skills when teaching OR teamwork is artificial and may even be damaging, because such an approach could produce teams with excellent communication skills as they unsuccessfully manage the patient. OR simulations offer a unique opportunity to research how to best integrate both of these domains to improve patient care.

OBJECTIVES: Mentoring, for physicians and surgeons in training, is advocated as an essential adjunct in work-based learning, providing support in career and non-career related issues. The World Wide Web (WWW) has evolved, as a technology, to become more interactive and person centric, tailoring itself to the individual needs of the user. This changing technology may open new avenues to foster mentoring in medicine.

INTRODUCTION: The surgical training for endoscopic proficiency program is a collaborative project between Society of American Gastrointestinal and Endoscopic Surgeons and Olympus America Inc. dedicated to providing flexible endoscopy training to surgery residency programs. Currently it lacks models for proficiency-based training. This study developed 2 novel flexible endoscopy simulators, purchased a third, and established face and content validity as well as proficiency metrics for all 3. METHODS: Three simulators were tested-a foam and cardboard upper gastrointestinal tract model, a commercially available colonoscopy model (CM-15, Olympus, Japan), and an endoscopic targeting model created from the Operation Game (Hasbro). Time and errors for the performance of 12 expert surgical endoscopists on each model were used to calculate proficiency scores. Face validity and content validity were established through posttest questionnaires using a 5-point Likert scale. RESULTS: Experts had a mean of 8 years of endoscopic practice (range: 1-24 y). Among them, 83% teach residents or fellows using simulation. Most perform more than 50 upper endoscopies (51 to 4500) and 100 colonoscopies (101 to 4500) per year. The average time for completing the upper gastrointestinal tract model with correct identification of all targets was 133 Ϯ 56 seconds. Complete navigation of the colonoscopy model averaged 325 Ϯ 156 seconds. Proper orientation and targeting using the Operation Game model averaged 273 Ϯ 109 seconds with 3 errors. CONCLUSIONS: This study proves face and content validity for 3 physical flexible endoscopy simulators that can be used to train upper and lower endoscopy as well as instrument targeting. It also establishes expert proficiency metrics that can be used by trainees for structured rehearsal. These relatively inexpensive models will be incorporated into the surgical training for endoscopic proficiency curriculum. (

This study attempts to assess the association between surgeon personality factors (measured by the Myers-Briggs Type Indicator personality inventory (MBTI ®)) and risk tolerance (measured by the Revised Physicians' Reactions to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales). DESIGN: Instrument assessing surgeon personality profile (MBTI) and 2 questionnaires measuring surgeon risk tolerance and risk aversion (PRU and PRA).

Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the effects of intra-operative stress on surgical performance.A systematic search strategy was implemented to obtain relevant articles. MEDLINE, EMBASE, and PsycINFO databases were searched, and 3,547 abstracts were identified. After application of limits, 660 abstracts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by 2 reviewers.In all, 22 articles formed the evidence base for this review. Key stressors included laparoscopic surgery (7 studies), bleeding (4 studies), distractions (4 studies), time pressure (3 studies), procedural complexity (3 studies), and equipment problems (2 studies). The methods for assessing stress and performance varied greatly across studies, rendering cross-study comparisons difficult. With only 7 studies assessing stress and surgical performance concurrently, establishing a direct link was challenging. Despite this shortfall, the direction of the evidence suggested that excessive stress impairs performance. Specifically, laparoscopic procedures trigger greater stress levels and poorer technical performance (3 studies), and expert surgeons experience less stress and less impaired performance compared with juniors (2 studies). Finally, 3 studies suggest that stressful crises impair surgeons' nontechnical skills (eg, communication and decision making).Surgeons are subject to many intra-operative stressors that can impair their performance. Current evidence is characterized by marked heterogeneity of research designs and variable study quality. Further research on stress and performance is required so that surgical training and clinical excellence can flourish.

BACKGROUND: The Surgical Morbidity and Mortality (M&M) conference is considered the golden hour of surgical education. However, evaluation methods for ensuring that quality M&M presentations efficiently contribute to resident education have not been clearly defined. To provide surgical trainees with the skills required to present a quality M&M presentation it is essential to have a robust tool to measure presentation skill and guide formative feedback. METHODS: A prospective observational study was conducted to develop an assessment tool for M&M conference. Literature review and expert consensus provided content for tool development. The tool, created using the situation, background, assessment, and recommendation format, was refined successively based on assessor feedback and assessed for reliability (internal consistency, interassessor reliability) and construct validity. RESULTS: Three successive iterations of the tool were developed. Internal consistency and interassessor reliability improved from the first to third versions. A trend also was shown for increasing construct validity with the third iteration of the tool. CONCLUSIONS: A psychometrically robust assessment tool based on the situation, background, assessment, and recommendation format was developed and validated to identify and improve the overall quality and educational value of the surgical M&M conference.

Optimal team performance in the operating room (OR) requires a combination of interactions among OR professionals and adherence to clinical guidelines. Theoretically, it is possible that OR teams could communicate very well but fail to follow acceptable standards of patient care and vice versa. OR simulations offer an ideal research environment to study this relationship. The goal of this study was to determine the relationship between ratings of OR teamwork and communication with adherence to patient care guidelines in a simulated scenarios of malignant hyperthermia (MH). An interprofessional research team (2 anesthesiologists, 1 surgeon, an OR nurse, and a social scientist) reviewed videos of 5 intraoperative teams managing a simulated patient who manifested MH while undergoing general anesthesia for an epigastric herniorraphy in a high-fidelity, in situ OR. Participant teams consisted of 2 residents from anesthesiology, 1 from surgery, 1 OR nurse, and 1 certified surgical technician. Teamwork and communication were assessed with 4 published tools: Anesthesiologists' Non-Technical Skills (ANTS), Scrub Practitioners List of Intra-operative Non-Technical Skills (SPLINTS), Non-Technical Skills for Surgeons (NOTSS), and Objective Teamwork Assessment System (OTAS). We developed an evidence-based MH checklist to assess overall patient care. Interrater agreement for teamwork tools was moderate. Average rater agreement was 0.51 For ANTS, 0.67 for SPLINTS, 0.51 for NOTSS, and 0.70 for OTAS. Observer agreement for the MH checklist was high (0.88). Correlations between teamwork and MH checklist were not significant. Teams were different in percent of the MH actions taken (range, 50-91%; P = .006). In this pilot study, intraoperative teamwork and communication were not related to overall patient care management. Separating nontechnical and technical skills when teaching OR teamwork is artificial and may even be damaging, because such an approach could produce teams with excellent communication skills as they unsuccessfully manage the patient. OR simulations offer a unique opportunity to research how to best integrate both of these domains to improve patient care.

Background Teamwork in surgical teams is at the forefront of good practice guidelines and empirical research as an important aspect of safe surgery. We have developed a comprehensive assessment for teamwork in surgery-the Observational Teamwork Assessment for Surgery (OTA-S)-and we have tested it for general surgical procedures. The aim of the research reported here was to extend the assessment to urology procedures. Methods After refining the original assessment, we used it to observe 50 urology procedures. The OTAS comprises a procedural task checklist that assesses patient, equipment/ provisions, and communication tasks as well as ratings on five team behavior constructs (communication, cooperation, coordination, leadership, and monitoring). Teamwork was assessed separately in the surgical, anesthesia, and nursing subteams in the operating theater. We also assessed the reliability of the behavioral scoring. Results Regarding task completion, a number of communication and equipment/provisions tasks were not routinely performed during the operations we observed. Regarding teamwork-related behaviors, adequate reliability was obtained in the scoring of behaviors. Anesthetists and nurses obtained their lowest scores on communication.

BACKGROUND: Failures in nontechnical and teamwork skills frequently lie at the heart of harm and near-misses in the operating room (OR). The purpose of this systematic review was to assess the impact of nontechnical skills on technical performance in surgery. STUDY DESIGN: MEDLINE, EMBASE, PsycINFO databases were searched, and 2,041 articles were identified.

The first objective was to assess percutaneous renal access (PCA) skills of urology postgraduate trainees (PGTs) during the Objective Structured Clinical Examinations (OSCEs). The second objective was to determine whether previous experience with percutaneous nephrolithotomy (PCNL) improved performance. After obtaining ethics approval, we recruited PGTs from two urology programs in Quebec between postgraduate years (PGY-3 to PGY-5). Each trainee was asked to answer a short questionnaire regarding previous experience in endourologic procedures. After a 3-minute orientation on the PERC Mentor simulator (Simbionix, Cleveland, OH), each trainee was asked to perform task 4, where they had to correctly access all of the renal calyces and pop the balloons in a normal left kidney model. We collected and analyzed data from the questionnaire and the performance report generated by the simulator. In total, 13 PGTs participated in this study. PGTs had performed a median of 200 (range: 50-1000) ...

Background Stress can impair surgical performance and may compromise patient safety. This prospective, crosssectional study describes the feasibility, reliability, and validity of the Imperial Stress Assessment Tool (ISAT) as an approach to measuring stress during surgery. Methods A total of 54 procedures were observed with 11 surgeons (4 attendings, 4 senior residents and 3 junior residents) in a large university teaching hospital in London, UK. Data collection involved physiological measures of operating surgeons [heart rate (HR) and salivary cortisol] and self-report questionnaires (State Trait Anxiety Inventory, or STAI). Results In all, 23 of 54 procedures were stressful, as identified by self-reporting. For stressful procedures compared to nonstressful ones, STAI was higher (mean ± SD) 9.81 ± 2.20 vs. 12.87 ± 4.27, t (30.64) = 3.15 as was the HR (mean ± SD) 79.94 ± 8.55 vs. 93.17 ± 14.94, t(32.57) = 3.81) (p \ 0.05). Significant positive correlations were obtained between the measures indicating concurrent validity: Pearson's r = 0.47 (HR vs. STAI), 0.34 (cortisol vs. STAI), and 0.57 (HR vs. cortisol) (p \ 0.05). Perfect correlation of subjective and objective measures was found for 70% of the procedures. HR and cortisol had specificities of 78% and 91% and sensitivities of 91% and 70% respectively for detecting stress during surgery. Conclusion ISAT is a nonintrusive, feasible approach that combines subjective and objective methods for measuring stress in the operating room. The ISAT may increase understanding of the effects of stress on clinical performance and outcomes, leading to improved patient care.

PURPOSE: Surgical education is undergoing a revolution in its approach to training. Duty-hour limitations, the need for strong teamwork, and increased cross-coverage have all impacted the culture of a surgical residency. This, combined with the profound shift in our culture at large has led to the suggestion that our specialty is attracting a different or more "modern" trainee (Generation X) with personality attributes that differ considerably from previous surgical residents. Historically, personality profiling of surgeons (Myers-Briggs Type Indicator (MBTI)) has favored the ESTJ personality type [extroversion (E), sensing (S), thinking (T), and judging (J)]. We hypothesized that the changing surgical training paradigms are attracting a different personality profile. To test this, we administered the MBTI examination to a large cohort of surgical trainees in one academic surgical training program.

OBJECTIVES
The first objective was to assess percutaneous renal access (PCA) skills of urology Post-Graduate Trainees (PGTs) during Objective Structured Clinical Examination (OSCEs). The second objective was to determine whether previous experience with Percutaneous Nephrolithotomy (PCNL) improved performance.
METHODS
After obtaining ethics approval, PGTs from two urology programs in Quebec between Post-Graduate Years (PGY-3 to PGY-5) were recruited. Each trainee was asked to answer a short questionnaire regarding previous experience in endourologic procedures. After a 3-minute orientation on the PERC Mentor™ simulator, each trainee was asked to perform task 4, where they had to correctly access all of the renal calyces and pop the balloons in a normal left kidney model. Data from the questionnaire and the performance report generated by the simulator were collected and analyzed.
RESULTS
Thirteen PGTs participated in this study. PGTs had performed a median of 200 (50-1000) cystoscopies, 50 (10-125) TURBTs, 30 (0-100) TURPs, 5 (0-50) laser prostatectomies, and 50 (2-125) ureteroscopies prior to this OSCE. PGTs with previous PCNL experience (8/13) had performed a mean of 18.6±6.3 PCNLs. When compared with PGTs without previous PCNL experience, PGTs with previous PCNL experience performed significantly better in terms of shorter fluoroscopy time (FT) (10±1.5 vs. 5.1±0.7 min; p=0.04), fewer attempts required for successful puncture of the pelvi-calyceal system (PCS) (21±2.3 vs. 13±1.8; p=0.02), and had significantly lower complications in terms of fewer infundibular injury (7.4±1.5 vs. 2±0.4; p=0.004) and fewer PCS perforations (11±1.7 vs. 4.5±1.2; p=0.01).
CONCLUSION
It is feasible to use the PERC Mentor™ simulator during OSCEs to assess PCA skills of urology PGTs. PGTs who had previous PCNL experience performed significantly better with fewer complications.

RESUMEN
El síndrome de Peutz-Jeghers es una condición hereditaria autosómica dominante caracterizada por la presencia de pólipos hamartomatosos, más comúnmente encontrados en el intestino delgado, ocasionalmente ocurren en el estomago y el colon. La mucosa oral y la pigmentación facial son características adicionales. Estos pólipos pueden causar obstrucción intestinal en 43% de los casos y sangrado rectal en un 14 % de los pacientes. Sin embargo la recurrencia de episodios de intususcepción ocurre en al menos 10% de los casos resultando en repetidas laparotomías. Con el uso de la laparoscopia muchas laparotomías son abolidas al igual que sus complicaciones.
Palabras clave: intususcepción, Peutz-Jeghers, pólipos, laparoscopia.

Accurate and legible record keeping is a crucial part of good medical practice. Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors. The author has designed the tool, based on the Royal College of Surgeons guidelines, to anonymously score the different surgical teams' medical records within a hospital. It takes into account regular record keeping during ward rounds, together with the operation note and admission clerking.The SHARK audit tool assesses 45 individual areas within surgical records. Fifteen points are apportioned for an initial surgical clerking, 13 for a subsequent record entry, and 17 for the operation note to give an overall score out of 45. It was implemented at 2 hospitals and used to educate medical students.The results were poor and improved with education at both sites. There was 80% total agreement with a κ coefficient for interobserver reliability of 0.6.This study shows that the SHARK tool is simple to use, repeatable, and reliable in improving record keeping.

Background: The significant global variations in surgical oncology training paradigms can have a detrimental effect on tackling the rising global cancer burden. While some variations in training are essential to account for the differences in types of cancer and biology, the fundamental principles of providing care to a cancer patient remain the same. The development of a global curriculum in surgical oncology with incorporated essential standards could be very useful in building an adequately trained surgical oncology workforce, which in turn could help in tackling the rising global cancer burden. Materials and methods: The leaders of the Society of Surgical Oncology and European Society of Surgical Oncology convened a global curriculum committee to develop a global curriculum in surgical oncology. Results: A global curriculum in surgical oncology was developed to incorporate the required domains considered to be essential in training a surgical oncologist. The curriculum was constructed in a modular fashion to permit flexibility to suit the needs of the different regions of the world. Similarly, recognizing the various sociocultural, financial and cultural influences across the world, the proposed curriculum is aspi-rational and not mandatory in intent. Conclusions: A global curriculum was developed which may be considered as a foundational scaffolding for training surgical oncologists worldwide. It is envisioned that this initial global curriculum will provide a flexible and modular scaffolding that can be tailored by individual countries or regions to train surgical oncologists in a way that is appropriate for practice in their local environment.

OBJECTIVE: Few tasks are more ingrained within the minds of practicing surgeons than the dictation of the narrative report of an operation. However, the construct of these reports varies widely among surgeons and is rarely formally taught and not tested formally during surgical training or board certification.

Introduction and Objectives: To evaluate the utility of the GreenLight-SIM™ (GL-SIM) simulator to assess photoselective vaporization of the prostate (PVP) skills of urology postgraduate trainees (PGTs) during Objective Structured Clinical Examinations (OSCEs).
Methods: After obtaining ethics approval, PGTs in Post- Graduate Years (PGY-3 to PGY-5) from all four Quebec urology training programs were recruited during two annual OSCEs. During a 20-minute OSCE station, PGTs were asked to perform two exercises: identification of endoscopic landmarks and PVP of a 30 g normal prostate. Grams vaporized, global scores and number of correct anatomical landmarks were recorded and correlated with PGY level, practice on the GL-SIM and previous PVP experience.

Results: 25 PGTs were recruited at each OSCE with 13 PGTs participating in both OSCEs. When comparing scores from the 1st to the 2nd OSCE, there was a significant improvement in the number of grams vaporized (2.9 vs. 4.3 g; p = 0.003) and global score (100 vs. 165; p = 0.03). There was good correlation between the number of previously performed PVPs and the global score (r = 0.4, p = 0.04). Similarly, PGTs with previous practice on the GL-SIM had significantly higher global score (100.6 vs. 162.6; p = 0.04) and grams vaporized (3.1 vs 4.1 g; p = 0.04) when compared with those who did not practice on GL-SIM. PGY level did not significantly affect grams vaporized and global score (p > 0.05).

Conclusions: Performance on the GreenLight-SIM at OSCEs significantly correlated with previous practice on the GL-SIM simulator and previous PVP experience rather than PGY level.

Source of Funding: None

e-Learning involves the delivery of educational content through web-based methods. Owing to work-hour restrictions and changing practice patterns in surgery, e-learning can offer an effective alternative to traditional teaching. Our aims were to (1) identify current modalities of e-learning, (2) assess the efficacy of e-learning as an intervention in surgical education through a systematic review of the literature, and (3) discuss the relevance of e-learning as an educational tool in surgical education. This is the first such systematic review in this field. A systematic search of MEDLINE and EMBASE was conducted for relevant articles published until July 2014, using a predefined search strategy. The database search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 38 articles were found which met the inclusion criteria. In these studies, e-learning was used as an intervention in 3 different ways: (1) to...

Clinical Assessment and Management Examination--Outpatient (CAMEO) is a metric for evaluating the clinical performance of surgery residents. The aim of this study was to investigate the measurement characteristics of CAMEO and propose how it might be used as an evaluation tool within the general surgery milestones project. A total of 117 CAMEO evaluations were gathered and used for analysis. Internal consistency reliability was estimated, and item characteristics were explored. A Kruskal-Wallis procedure was performed to discern how well the instrument discriminated between training levels. An exploratory factor analysis was also conducted to understand the dimensionality of the evaluation. CAMEO evaluations were collected from 2 departments of surgery geographically located in the Midwestern United States. Combined, the participating academic institutions graduate approximately 18 general surgery residents per year. In this retrospective data analysis, the number of evaluations per...

The purpose of this study was to determine the effectiveness of weekly didactic grand rounds presentations. DESIGN: From 26 consecutive grand rounds presentations from July 2007 to March 2008, 2 questions were created from each lecture. A 52-question multiple choice test was administered 2 weeks after the completion of the last presentation.

Objective: To assess the effects of mental practice on surgical performance. Background: Increasing concerns for patient safety have highlighted a need for alternative training strategies outside the operating room. Mental practice (MP), "the cognitive rehearsal of a task before performance," has been successful in sport and music to enhance skill. This study investigates whether MP enhances performance in laparoscopic surgery. Methods: After baseline skills testing, 20 novice surgeons underwent training on an evidence-based virtual reality curriculum. After randomization using the closed envelope technique, all participants performed 5 Virtual Reality (VR) laparoscopic cholecystectomies (LC). Mental practice participants performed 30 minutes of MP before each LC; control participants viewed an online lecture. Technical performance was assessed using video Objective Structured Assessment of Technical Skills-based global ratings scale (scored from 7 to 35). Mental imagery was assessed using a previously validated Mental Imagery Questionnaire. Results: Eighteen participants completed the study. There were no intergroup differences in baseline technical ability. Learning curves were demonstrated for both MP and control groups. Mental practice was superior to control (global ratings) for the first LC (median 20 vs 15, P = 0.005), second LC (20.5 vs 13.5, P = 0.001), third LC (24 vs 15.5, P < 0.001), fourth LC (25.5 vs 15.5, P < 0.001) and the fifth LC (27.5 vs 19.5, P = 0.00). The imagery for the MP group was also significantly superior to the control group across all sessions (P < 0.05). Improved imagery significantly correlated with better quality of performance (ρ 0.51-0.62, Ps < 0.05). Conclusions: This is the first randomized controlled study to show that MP enhances the quality of performance based on VR laparoscopic cholecystectomy. This may be a time-and cost-effective strategy to augment traditional training in the OR thus potentially improving patient care. (Ann Surg 2011;253:265-270) From the

Rationale The aim of the research that we report here was to empirically assess the cohesiveness of the multidisciplinary operating theatre (OT) team. Method We used concepts from the team performance and team mental models literature to assess OT professionals' perceptions of their teamwork, the structure of their teams and their respective roles within them and their teams' performance. Results Team structure : OT professionals would welcome a change from the current structure of the team, although there was no agreement on what that structure is. Nurses perceived the team as unitary, surgeons and anaesthetists perceived it as comprising multiple subteams. Team roles : OT professionals tended to overrate their own understanding of their colleagues' role in the OT relative to the role understanding that the colleagues attributed to them. This tendency was especially marked for the surgeons. Team communication and team performance : OT professionals agreed on the relative importance of the various communicating pairs in the OT. Moreover, they were satisfied with the quality of communication among them, except for the communication between the surgeon and the anaesthetist, which received lower ratings. Finally, the quality of the teamwork in the OT was deemed acceptable, although there is room for improvement. Conclusions The OT environment need not be as cohesive as previously assumed -a finding that carries implications for the effectiveness of team training interventions. Further research is needed in order to fully comprehend the dynamics of the OT as a working environment and, most importantly, their relation to patient safety.