title: Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions.
abstract: BACKGROUND
  Poor communication is a known contributor to disasters in aviation and medicine. Crew members are trained to raise concerns about superiors' plans, yet literature exploring surgical trainees' responses to analogous concerns is sparse.
  
  
  METHODS
  Surgical residents were interviewed about approaches to concerns about supervisors' clinical decisions using a semistructured guide. Emerging themes were developed using the constant comparative method.
  
  
  RESULTS
  Eighteen residents participated. They expressed a tension between conceding ultimate decision-making authority to supervisors and prioritizing obligations to the patient. Systemic (eg, departmental culture, resident autonomy), supervisor (eg, approachability), trainee (eg, knowledge), and clinical (eg, risk of harm, evidence quality) factors influenced the willingness to voice concerns. Most described verbalizing concerns in question form, whereas some reported expressing concerns directly.
  
  
  CONCLUSIONS
  Several factors affect surgical trainees' management of concerns about supervisors' plans. No consistent method is used. A tailored curriculum addressing strategies to raise concerns appears warranted to optimize patient safety.
authors.affiliation: Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Ave., MC6040, Chicago, IL 60637, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, 5841 S. Maryland Ave., MC6040, Chicago, IL 60637, USA. Electronic address: msur@post.harvard.edu.
authors.forename: Malini D
authors.initials: MD
authors.lastname: Sur
authors.affiliation: Pritzker School of Medicine, University of Chicago, Chicago, IL, USA; Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Schindler
authors.affiliation: Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Ave., MC6040, Chicago, IL 60637, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, 5841 S. Maryland Ave., MC6040, Chicago, IL 60637, USA.
authors.forename: Puneet
authors.initials: P
authors.lastname: Singh
authors.affiliation: Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Ave., MC6040, Chicago, IL 60637, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, 5841 S. Maryland Ave., MC6040, Chicago, IL 60637, USA; Bucksbaum Institute for Clinical Excellence, University of Chicago, Chicago, IL, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Angelos
authors.affiliation: MacLean Center for Clinical Medical Ethics, University of Chicago, 5841 S. Maryland Ave., MC6040, Chicago, IL 60637, USA; Bucksbaum Institute for Clinical Excellence, University of Chicago, Chicago, IL, USA; Department of Otolaryngology-Head and Neck Surgery, University of Chicago Medicine, Chicago, IL, USA; Operative Performance Research Institute, University of Chicago, Chicago, IL, USA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Langerman
mesh_terms: D000367:Age Factors; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D000066491:Clinical Decision-Making; D003479:Curriculum; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D007396:Internship and Residency; D008297:Male; D009042:Motivation; D017009:Professional Autonomy; D013043:Specialties, Surgical / Q000193:education*
keywords: Communication; Ethics; Patient safety; Qualitative research; Surgical residents