The investigation demonstrates a scenario where a neurotologic surgeon, Dr. Anya Sharma, faces a conflict between patient autonomy and the potential for significant harm due to a rare genetic predisposition identified during pre-operative genetic screening. The challenge lies in balancing the patient’s right to make informed decisions about their health, even if those decisions carry risks, with the surgeon’s ethical duty to prevent harm and act in the patient’s best interest. This is particularly complex in neurotologic surgery due to the intricate nature of the procedures and the potential for irreversible neurological deficits. Careful judgment is required to navigate the ethical minefield of disclosure, patient capacity, and the surgeon’s professional responsibility. The best professional practice involves a comprehensive and empathetic discussion with the patient, ensuring full understanding of the implications of the genetic finding and the associated surgical risks. This approach prioritizes informed consent by clearly articulating the increased risk of specific complications (e.g., facial nerve injury, cerebrospinal fluid leak, or hearing loss) directly attributable to the identified genetic variant, while also respecting the patient’s right to proceed with surgery if they choose to accept these heightened risks. This aligns with the fundamental ethical principles of patient autonomy and beneficence, as well as the regulatory requirement for thorough pre-operative counseling and risk disclosure, ensuring the patient can make a truly informed decision. Proceeding with surgery without a detailed discussion of the genetic predisposition and its specific implications for the planned procedure represents a failure to uphold the principle of informed consent. While the patient may have consented to the general risks of surgery, they were not adequately informed about the *specific* and *elevated* risks associated with their unique genetic profile, thereby undermining their autonomy. Disclosing the genetic finding to the patient’s family without the patient’s explicit consent, even with the intention of seeking their support, violates patient confidentiality and privacy. This breaches the ethical duty of confidentiality and potentially erodes the trust between the patient and the medical team. Refusing to operate solely based on the genetic finding without a thorough discussion and assessment of the patient’s understanding and willingness to accept the risks, effectively paternalistically overriding the patient’s autonomy, is ethically problematic. While the surgeon has a duty to prevent harm, this should be achieved through informed decision-making rather than unilateral prohibition, unless the patient demonstrably lacks capacity. The professional reasoning process should involve a structured approach: first, assess the patient’s capacity to understand the information; second, clearly and comprehensively explain the genetic finding, its implications for the specific surgical procedure, and the associated risks and benefits; third, explore the patient’s values, preferences, and understanding of the risks; fourth, document the discussion thoroughly; and finally, respect the patient’s informed decision, while continuing to offer support and alternative management strategies if appropriate.

This scenario presents a professional challenge due to the inherent conflict between a surgeon’s desire to advance their skills and the paramount duty to patient safety and informed consent. The need for careful judgment arises from balancing the potential benefits of a novel technique against the risks associated with its unproven application in a live patient, especially when the patient’s understanding of the experimental nature is compromised. The best professional approach involves prioritizing full transparency and obtaining explicit, informed consent from the patient before proceeding with any experimental aspect of the surgery. This entails clearly explaining that the proposed technique is not standard practice, detailing the potential risks and benefits compared to established methods, and ensuring the patient understands they have the right to refuse this experimental approach. This aligns with fundamental ethical principles of patient autonomy and beneficence, as well as regulatory requirements for informed consent in medical procedures, particularly those involving novel or investigational treatments. The surgeon must also ensure they have the necessary institutional review board (IRB) or ethics committee approval if the procedure is considered research. An approach that involves proceeding with the experimental technique without fully disclosing its investigational nature to the patient, or by downplaying the associated risks, is ethically and regulatorily unacceptable. This violates the principle of informed consent, potentially leading to patient harm without their genuine agreement, and breaches the trust inherent in the patient-physician relationship. It also fails to adhere to guidelines that mandate transparency regarding experimental medical interventions. Another unacceptable approach would be to perform the standard procedure and then, without prior consent, attempt the novel technique as an add-on. This circumvents the patient’s right to make decisions about their own body and treatment, and exposes them to risks they did not agree to undertake. It constitutes a breach of ethical conduct and potentially legal regulations governing medical practice. Finally, an approach that relies solely on the surgeon’s personal conviction about the technique’s superiority, without seeking explicit patient consent or appropriate ethical review, is also professionally unsound. While a surgeon’s expertise is valuable, it does not supersede the patient’s right to self-determination and the requirement for rigorous ethical and regulatory oversight of novel medical practices. Professionals should employ a decision-making framework that begins with identifying the ethical and regulatory obligations. This involves a thorough understanding of informed consent principles, patient autonomy, and any specific guidelines governing experimental procedures within their practice setting. When faced with a novel technique, the process should include seeking ethical review, ensuring comprehensive patient education, and obtaining documented consent that clearly articulates the experimental nature of the intervention and its associated risks and benefits.

This scenario presents a professional challenge due to the inherent conflict between a physician’s duty to provide optimal patient care and the potential for financial gain influencing medical decisions. The practice of otologic and neurotologic surgery in Sub-Saharan Africa often operates within resource-constrained environments, making ethical considerations paramount. Careful judgment is required to ensure that patient welfare remains the sole determinant of treatment recommendations, free from any undue influence. The approach that represents best professional practice involves a transparent and comprehensive discussion with the patient regarding all available treatment options, including their respective risks, benefits, and costs, without any personal financial incentive influencing the recommendation. This aligns with the fundamental ethical principles of patient autonomy and beneficence, as well as the professional guidelines of medical associations that mandate physicians act in the best interests of their patients. Specifically, it upholds the principle of informed consent, ensuring the patient can make a decision based on complete and unbiased information. An incorrect approach involves recommending a specific, more expensive treatment solely because it offers a personal financial benefit, such as a commission or referral fee, without fully disclosing this incentive to the patient. This constitutes a breach of fiduciary duty and can lead to patient harm if the recommended treatment is not the most appropriate or if less costly, equally effective alternatives exist. Such an action violates ethical codes that prohibit conflicts of interest and prioritize patient well-being above physician financial gain. Another incorrect approach is to withhold information about less expensive, equally effective treatment options to steer the patient towards a more profitable procedure. This undermines patient autonomy and the principle of informed consent. Patients have a right to know all viable treatment pathways and their associated implications, allowing them to make a truly informed choice. Failing to provide this comprehensive information is a serious ethical lapse. A further incorrect approach involves pressuring the patient into accepting a particular treatment by exaggerating the risks of alternative options or downplaying their benefits, especially when this pressure is motivated by personal financial gain. This manipulative tactic not only violates ethical standards of honesty and integrity but also exploits the patient’s vulnerability and trust in their physician. The professional decision-making process for similar situations should involve a rigorous self-assessment of potential conflicts of interest. Physicians must prioritize their ethical obligations to patients above any personal financial considerations. When faced with a situation where personal gain might influence a medical decision, the professional should: 1) Identify the potential conflict of interest. 2) Disclose any relevant financial interests to the patient transparently. 3) Present all medically appropriate treatment options, detailing their risks, benefits, and costs without bias. 4) Ensure the patient’s decision is based on their own values and understanding, free from coercion or undue influence. 5) If the conflict of interest is significant and cannot be adequately managed through disclosure and patient consent, the physician should consider referring the patient to another practitioner.

Scenario Analysis: This scenario presents a significant ethical and professional challenge due to the inherent conflict between immediate patient needs in a critical care setting and the established protocols for resource allocation and informed consent, particularly when dealing with a vulnerable patient population in a resource-constrained environment. The urgency of the situation demands swift action, yet the principles of patient autonomy and equitable treatment must be upheld. The physician must balance the immediate life-saving imperative with the long-term implications of their decisions on patient care and the healthcare system. Correct Approach Analysis: The best professional approach involves prioritizing immediate life-saving interventions while simultaneously initiating the process for obtaining informed consent as soon as the patient’s condition permits. This means stabilizing the patient and addressing immediate threats to life, such as severe bleeding or airway compromise, using standard emergency protocols. Concurrently, the medical team should begin to assess the patient’s capacity to consent and, if capacity is lacking, identify and involve the appropriate surrogate decision-maker. This approach respects the principle of beneficence by acting to save the patient’s life, while also upholding the principle of autonomy by seeking consent as soon as feasible and involving the patient or their representative in future treatment decisions. This aligns with ethical guidelines that emphasize acting in the patient’s best interest while respecting their rights. Incorrect Approaches Analysis: Initiating invasive, potentially life-altering procedures without any attempt to obtain consent or involve a surrogate decision-maker, even in a critical situation, represents a failure to respect patient autonomy. While the intent may be to save a life, bypassing consent entirely, unless in a dire emergency where no surrogate is available and the patient is unconscious, can lead to ethical breaches and potential legal ramifications. It assumes the patient would consent to all interventions without their input. Delaying critical interventions to exhaust all avenues of consent from a potentially unavailable or unidentifiable surrogate decision-maker, when the patient’s life is in immediate peril, violates the principle of beneficence. The primary duty in a critical care setting is to preserve life and prevent further harm. Prolonged delays for consent in such circumstances can lead to irreversible damage or death, making the physician negligent. Proceeding with interventions based solely on the perceived urgency without documenting the rationale for bypassing or delaying consent, or without a clear plan to involve a surrogate, demonstrates a lack of professional accountability and adherence to established ethical and legal frameworks for emergency care. This can lead to a breakdown in trust and a failure to provide comprehensive, patient-centered care. Professional Reasoning: Professionals should employ a tiered approach to decision-making in critical care trauma. First, assess the immediate life threats and initiate necessary resuscitation protocols to stabilize the patient. Second, concurrently assess the patient’s capacity to consent and identify any available surrogate decision-makers. If the patient has capacity, obtain informed consent for necessary interventions. If the patient lacks capacity, involve the surrogate decision-maker to obtain consent, explaining the risks, benefits, and alternatives. If no surrogate is immediately available and the situation is life-threatening, proceed with life-saving interventions under the principle of implied consent or necessity, documenting the circumstances thoroughly and making every effort to contact a surrogate as soon as possible. This framework prioritizes patient well-being while upholding ethical and legal obligations.

The risk matrix shows a moderate likelihood of a significant complication arising from a complex otologic procedure. This scenario is professionally challenging due to the inherent unpredictability of surgical outcomes, the potential for severe patient harm, and the physician’s duty of care. Careful judgment is required to balance the potential benefits of the procedure against its risks, and to ensure that patient autonomy and informed consent are respected throughout the process. The best approach involves a thorough pre-operative discussion with the patient, clearly outlining the specific risks and potential complications of the subspecialty procedure, including the likelihood and severity of each. This discussion must also cover the available management strategies for any identified complications, ensuring the patient understands the potential post-operative course and treatment options. This aligns with the ethical principle of informed consent, which mandates that patients have the right to make autonomous decisions about their medical care based on adequate information. Furthermore, it adheres to professional guidelines that emphasize transparency and patient-centered communication in managing surgical risks. An approach that downplays the potential for complications or fails to adequately explain management strategies is ethically unacceptable. This constitutes a failure to obtain true informed consent, potentially misleading the patient about the true nature and risks of the surgery. It also breaches the physician’s duty to provide comprehensive information necessary for the patient to make a reasoned decision. Another professionally unacceptable approach is to proceed with the surgery without a clear, pre-defined plan for managing anticipated complications. This demonstrates a lack of preparedness and foresight, potentially leading to delayed or suboptimal treatment if a complication arises, thereby jeopardizing patient safety and violating the physician’s responsibility to act in the patient’s best interest. Finally, an approach that focuses solely on the technical aspects of the surgery without adequately addressing the patient’s concerns or providing clear avenues for post-operative support and complication management is also ethically flawed. This neglects the holistic care of the patient and can lead to increased anxiety and distress, particularly if complications do occur. Professionals should employ a decision-making framework that prioritizes open and honest communication, thorough risk assessment, comprehensive pre-operative counseling, and robust post-operative care planning. This framework should be guided by ethical principles of beneficence, non-maleficence, autonomy, and justice, ensuring that patient well-being and informed choice are at the forefront of all clinical decisions.

This scenario presents a significant ethical and professional challenge for a surgeon specializing in otologic and neurotologic surgery in Sub-Saharan Africa. The core dilemma lies in balancing the immediate need for a potentially life-saving procedure with the ethical obligation to ensure the patient’s informed consent and the availability of appropriate resources and expertise, particularly concerning advanced energy device safety. The scarcity of resources and specialized training in the region exacerbates this challenge, requiring careful consideration of patient welfare, professional integrity, and adherence to established surgical principles. The best professional approach involves prioritizing patient safety and informed consent above all else, even if it means delaying or modifying the surgical plan. This entails a thorough assessment of the patient’s condition, a clear and understandable explanation of the proposed procedure, including the risks and benefits associated with the specific energy device, and confirmation of the patient’s comprehension and voluntary agreement. If the surgeon or the available instrumentation does not meet the highest safety standards for the chosen energy device, or if the patient cannot fully comprehend the implications due to language barriers or cognitive impairment, the surgeon has an ethical duty to explore alternative, safer approaches or to postpone the procedure until adequate conditions are met. This aligns with the fundamental ethical principles of beneficence, non-maleficence, and respect for patient autonomy, which are universally recognized in medical practice and are implicitly supported by professional guidelines emphasizing patient-centered care and responsible use of technology. An approach that proceeds with the surgery despite concerns about the energy device’s safety or the patient’s full comprehension is professionally unacceptable. This would constitute a breach of the duty of care, potentially leading to iatrogenic harm to the patient. Failing to adequately assess the patient’s understanding or proceeding with technology that is not fully understood or appropriately managed violates the principle of non-maleficence and patient autonomy. Similarly, opting for a more complex or potentially riskier surgical technique solely because it utilizes a familiar energy device, without a clear clinical justification and without ensuring the patient understands these trade-offs, is ethically questionable. It prioritizes the surgeon’s comfort over the patient’s best interest and informed decision-making. Professional decision-making in such situations requires a structured approach. First, the surgeon must rigorously assess the clinical necessity and urgency of the procedure. Second, a comprehensive evaluation of the available resources, including the suitability and safety of the chosen energy device and the surgeon’s proficiency with it, is paramount. Third, open and transparent communication with the patient is essential, ensuring they understand the procedure, its risks, benefits, and alternatives, and that their consent is truly informed and voluntary. If any of these elements are compromised, the surgeon must be prepared to modify the plan, seek further assistance, or postpone the procedure, always prioritizing the patient’s safety and well-being.

Scenario Analysis: This scenario presents a professional challenge for a candidate preparing for the Elite Sub-Saharan Africa Otologic and Neurotologic Surgery Practice Qualification. The core difficulty lies in balancing the desire for comprehensive preparation with the ethical imperative of maintaining patient confidentiality and avoiding any perception of unfair advantage or exploitation of current clinical practice for personal gain. The candidate must navigate the complexities of resource acquisition and timeline management without compromising professional integrity or regulatory adherence. Careful judgment is required to select preparation methods that are both effective and ethically sound. Correct Approach Analysis: The best professional practice involves a structured and ethical approach to candidate preparation. This includes identifying and utilizing publicly available, peer-reviewed literature, established surgical guidelines, and reputable online educational resources specifically curated for advanced otologic and neurotologic surgery. Furthermore, engaging in simulated practice sessions using anonymized case studies or hypothetical scenarios, and seeking mentorship from experienced practitioners who adhere to strict ethical protocols regarding patient data, represents the most appropriate strategy. This approach ensures that preparation is grounded in evidence-based practice, respects patient privacy, and aligns with the ethical standards expected of specialists in this field. The timeline should be realistic, allowing for deep understanding and skill refinement rather than superficial memorization, typically spanning several months to a year depending on the individual’s prior experience and the depth of the qualification. Incorrect Approaches Analysis: One incorrect approach involves directly accessing and utilizing unredacted patient records from current clinical practice for study purposes. This is a severe ethical and regulatory failure. It breaches patient confidentiality, a fundamental tenet of medical practice, and violates data protection laws and professional conduct guidelines that mandate the anonymization or explicit consent for the use of patient data. Such an action could lead to severe professional sanctions, including disciplinary action and loss of licensure. Another unacceptable approach is relying solely on informal discussions with colleagues about specific, identifiable patient cases encountered in their practice without proper anonymization or consent. While collegial discussion can be beneficial, sharing details that could lead to patient identification, even inadvertently, is ethically problematic and potentially breaches confidentiality. This approach lacks the rigor of evidence-based learning and risks compromising professional integrity. A further inappropriate method is to seek out or purchase proprietary question banks or study materials that are not officially sanctioned by the examination body and appear to be derived from leaked examination content or unauthorized sources. This not only undermines the integrity of the qualification process but also constitutes academic dishonesty. The timeline for preparation should not be dictated by the availability of such questionable resources, but rather by a systematic and ethical learning plan. Professional Reasoning: Professionals preparing for advanced qualifications should adopt a decision-making process that prioritizes ethical conduct and regulatory compliance above all else. This involves: 1) Understanding the examination’s scope and requirements through official documentation. 2) Identifying ethically sourced and reputable preparation resources, focusing on peer-reviewed literature, established guidelines, and accredited educational platforms. 3) Developing a realistic study timeline that allows for thorough comprehension and skill development, not rushed cramming. 4) Seeking mentorship from experienced professionals who can guide ethical practice and preparation strategies. 5) Regularly self-assessing progress and adapting the study plan as needed, always within ethical boundaries. Any preparation method that involves the compromise of patient confidentiality, academic dishonesty, or the use of unauthorized materials should be immediately discarded.

This scenario presents a professional challenge because it requires balancing the integrity of the qualification process with the personal circumstances of a candidate. The core tension lies in upholding the established blueprint weighting, scoring, and retake policies, which are designed to ensure a consistent and fair assessment of competence, against a request for an exception due to unforeseen personal hardship. Careful judgment is required to avoid compromising the standards of the qualification while also acting with compassion and fairness. The best professional approach involves adhering strictly to the established blueprint weighting, scoring, and retake policies. This means that the candidate must meet the outlined criteria for passing, including achieving the required score based on the established weighting of different assessment components, and if unsuccessful, must follow the defined retake procedures. This approach is correct because it upholds the principle of equal opportunity and fair assessment for all candidates. The blueprint weighting and scoring are meticulously designed to reflect the essential knowledge and skills required for elite otologic and neurotologic surgery practice. Deviating from these established parameters, even for sympathetic reasons, would undermine the validity and credibility of the qualification. Furthermore, the retake policies are in place to provide candidates with opportunities to demonstrate mastery if they initially fall short, ensuring that only those who meet the rigorous standards are certified. Upholding these policies demonstrates respect for the established framework and ensures that the qualification maintains its value and recognition within the professional community. An incorrect approach would be to grant a special dispensation by adjusting the candidate’s score or waiving a retake requirement based solely on their personal circumstances. This fails to uphold the integrity of the assessment process. The blueprint weighting and scoring are not arbitrary; they are designed to measure specific competencies. Altering these would create an unfair advantage for the candidate and devalue the qualification for others who met the standards through the prescribed process. Ethically, this would be a breach of fairness and equity. Another incorrect approach would be to allow the candidate to proceed to the next stage of their career without meeting the full requirements of the qualification, based on a promise to complete the assessment later. This bypasses the established policies and compromises the qualification’s purpose of certifying current competence. It introduces an unacceptable level of risk, as the candidate’s ability to perform complex surgical procedures would not have been adequately verified according to the established standards. This also sets a dangerous precedent, potentially leading to future requests for similar exceptions and eroding the overall quality assurance of the practice. A further incorrect approach would be to dismiss the candidate’s request for consideration entirely without exploring any potential avenues for support within the existing framework. While adherence to policy is crucial, a complete disregard for a candidate’s extenuating circumstances, without any attempt to guide them through the established procedures or offer support within those boundaries, could be seen as lacking in professional empathy. However, this is less of a direct breach of the qualification’s integrity than the other incorrect approaches, but it misses an opportunity for compassionate professional conduct. The professional decision-making process in such situations should involve a thorough understanding of the qualification’s blueprint, weighting, scoring, and retake policies. The first step is to clearly ascertain the candidate’s situation and how it impacts their ability to meet the assessment requirements. Then, evaluate whether any support or flexibility can be offered strictly within the existing, clearly defined policies. This might involve advising on available resources, clarifying the retake process, or ensuring the candidate understands the implications of their current standing. If the circumstances genuinely prevent adherence to the policies, the professional must firmly but empathetically explain why exceptions cannot be made and reiterate the established pathways for success. The focus must always remain on maintaining the integrity and fairness of the qualification process.

The scenario presents a professional challenge due to the inherent risks associated with complex otologic and neurotologic surgery, coupled with the ethical imperative to ensure patient safety and informed consent. Surgeons must balance the potential benefits of advanced procedures with the possibility of adverse outcomes, requiring meticulous planning and transparent communication. The need for structured operative planning with risk mitigation is paramount in this specialized field, where even minor deviations can have significant consequences. The best approach involves a comprehensive pre-operative assessment and detailed discussion with the patient. This includes a thorough review of imaging, patient history, and potential surgical approaches, identifying specific risks and benefits for the individual case. The surgeon must then clearly articulate these risks, including the likelihood and potential severity of complications, in a manner understandable to the patient. This structured planning process, documented meticulously, forms the bedrock of ethical surgical practice and robust risk mitigation. It aligns with the fundamental ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as the legal requirement for informed consent, ensuring the patient can make a truly autonomous decision. An approach that prioritizes the surgeon’s personal experience and intuition over detailed, documented risk assessment and patient discussion is ethically flawed. While experience is valuable, it cannot replace the systematic identification and communication of specific risks for a given procedure and patient. This failure to engage in structured planning and transparent communication can lead to inadequate risk mitigation and a violation of the patient’s right to informed consent. Another unacceptable approach is to proceed with surgery based solely on the perceived urgency of the condition without a detailed discussion of all potential risks and alternative management strategies. While urgency may necessitate prompt intervention, it does not negate the ethical and legal obligation to inform the patient about the full spectrum of risks, including those that might arise from the chosen surgical path or even from delaying the procedure. This can lead to a situation where the patient is unaware of significant potential harms. Finally, an approach that focuses primarily on the technical aspects of the surgery without adequately considering the patient’s individual circumstances, comorbidities, and preferences for risk tolerance is also professionally deficient. Structured operative planning must be patient-centered, acknowledging that what constitutes an acceptable risk for one individual may not be for another. This oversight can result in a plan that is technically sound but not ethically aligned with the patient’s values and best interests. Professionals should adopt a decision-making framework that begins with a thorough understanding of the patient’s condition and the available surgical options. This should be followed by a systematic identification and evaluation of all potential risks and benefits associated with each option, considering the patient’s unique profile. Crucially, this information must be communicated clearly and comprehensively to the patient, allowing for shared decision-making. Documentation of this process is essential for accountability and continuous improvement.

The review process indicates a scenario that is professionally challenging due to the inherent conflict between a surgeon’s desire to provide the best possible care and the ethical imperative to obtain informed consent, especially when dealing with complex procedures involving significant anatomical risks. The need for careful judgment arises from the potential for unforeseen anatomical variations that could necessitate intraoperative decisions deviating from the initial surgical plan, requiring a delicate balance between patient autonomy and beneficence. The correct approach involves a comprehensive discussion with the patient regarding potential anatomical variations and the implications of such findings for the surgical procedure. This includes clearly explaining that unexpected anatomical anomalies might require modifications to the planned surgical approach to ensure patient safety and optimal outcomes. The surgeon must then document this discussion thoroughly, emphasizing that any deviations from the original plan would be made solely in the patient’s best interest and to mitigate unforeseen risks. This approach aligns with the fundamental ethical principles of informed consent and patient autonomy, ensuring the patient is aware of potential complexities and has agreed to the surgeon’s prerogative to act in their best interest during surgery, even if it means deviating from the initial plan due to anatomical findings. This respects the patient’s right to make decisions about their own body while empowering the surgeon to act decisively when medically necessary. An incorrect approach would be to proceed with the surgery without explicitly discussing the possibility of significant anatomical variations and the potential need for intraoperative modifications. This failure to adequately inform the patient undermines the principle of informed consent, as the patient has not had the opportunity to understand and agree to the full scope of potential surgical interventions. Another incorrect approach would be to assume that any deviation from the plan due to anatomical findings is automatically acceptable without prior discussion, neglecting the patient’s right to be informed about significant changes to their treatment. This can lead to a breach of trust and potential ethical violations. Finally, a surgeon who decides to proceed with a significantly altered surgical plan due to anatomical findings without any attempt to communicate this to the patient or their representative, even post-operatively, fails to uphold transparency and respect for patient autonomy. Professional reasoning in such situations requires a proactive approach to patient communication. Surgeons should anticipate potential anatomical challenges based on their knowledge of surgical anatomy and imaging studies. Before any procedure, a thorough discussion should cover the standard anatomy, potential variations, the planned surgical approach, and the contingency plans for managing unexpected findings. This empowers patients to make informed decisions and fosters a collaborative relationship between the patient and the surgical team.