Concurrent Surgery A Surgeon’s Perspective

Griff Harsh MD, MA, MBA, FACS

Professor of Neurosurgery

Associate Dean, Postgraduate Education School of Medicine, Stanford University

Petrie-Flom Center

Harvard Law School

October 27, 2016

Surgeons’ Reactions

I: Fear

II: Introspection III: Resolution

Surgery

CONCURRENT SURGERY

CLASH IN THE NAME OF CARE OCT 25, 2015 It was a battle pitting a star surgeon against a great hospital, MGH. At Issue: Is it right or safe for surgeons to run two operations at once? Is it right that their patients may have no idea? The conflict has been waged for years. And it isn’t over yet.

The index case “At 7:42 a.m., Dr. Kirkham Wood, chief of MGH’s orthopedic spine service began a complex thoracic spinal fusion on a 70-year-old woman. 18 minutes later, he started multiple cervical corpectomies on Tony Meng. The two cases overlapped for 7 hours, but Wood wrote in Meng’s op note that he was “present for the entire case.” Tony Meng awoke paralyzed. Neurosurgeons later that night found his spinal cord herniated through a tear in the dura. Meng’s attorneys say he had no idea he was sharing Wood with another patient that day and that double-booking will play a prominent role in their malpractice lawsuit against Wood.”

Spotlight report precipitated immense interest

Public blogs “Reprehensible deception motivated by greed”

H Admin “Our surgeons almost never perform CS”

Physicians Highly variable Supportive “Acceptable and essential” Critical “Everyone knows, except the patient”

Lay Press “CS is widespread and concealed from patients” SPOTLIGHT: TTell us your double booking story

Surgeons We, too, are in the Spotlight!

Overlapping surgeries to face US Senate inquiry Senate Finance Committee, in a Feb 2016 letter to 20 top AMCs , “Patients are not being informed about Concurrent Surgery and thus might be unable to give informed consent” The Committee demanded: 1. Policies regarding concurrent surgery 2. Policies regarding disclosure of CS to patients 3. Policies, penalties to ensure S compliance 4. Data for each calendar year 2011-2015: Number of concurrent surgeries Number of surgeons performing CS Number of surgeries with any overlap Duration of overlap of any portion Maximum duration of overlap Number of violations of hospital policy

Key Issues regarding Concurrent Surgery

1) Definitions Concurrent Surgery vs Overlapping Surgery 2) Guidelines ACS Statement 3) Prevalence Factors 4) Arguments Pro Efficiency Training Safety 5) Arguments Con Safety Training Efficiency 6) A Balanced View Caveats 7) Consent Trust

SFC/CMS CS occurs when an attending surgeon is conducting procedures on two or more different patients in different operating rooms at the same time; an attending may bill only if present during all critical portions of a case. ACS CS occurs when critical components of procedures for which the primary surgeon is responsible are occurring all or in part at the same time; CS is not appropriate.

What is Concurrent Surgery ?

ACS: Surgeries may overlap/ be sequenced (a second case may be started) ONLY IF the critical elements of a first operation have been completed. If there is no reasonable expectation that the primary attending surgeon will need to return, a qualified practitioner may take over the first case, EXCEPT when the attending surgeon is performing critical portions of a second case; then, a second attending surgeon must be assigned responsibility for the first case.

N.B. The primary attending should not move back and forth between the cases. This occurs routinely, with a senior resident in one room and a fellow in the other.

What is Overlapping Surgery ?

Additional Definitions

“Critical portions” those for which essential technical expertise and surgical judgment are required to achieve an optimal patient outcome Who decides? - the Attending On what basis? – minimal data

“Immediately available” Reachable by page or electronically and able to return immediately Time 5, 10, 15 min (specified by local institution) Location nearby OR / clinic / office +/- video monitor

“Qualified practitioner” licensed professional with sufficient training Attending, fellow, resident, PA; (judged by attending, hospital)

“Backup attending” designated qualified attending surgeon Fellow / Clinical Instructor v Rank Faculty? Subspecialty expertise? Informal availability v call schedule?

Prevalence and Duration of Overlapping Surgery MGH 15 % (Ortho 25%) with scheduled overlap 3 % open incisions simultaneously = 1000 cases / year Wisconsin 1% an average of 15 min Stanford numerous examples of parallel schedules

Time/Room OR 18 (Right) OR 19 (Left) 7-10 am Patient A1 Patient B1 11-2 pm Patient A1 Patient B1 3-6 pm Patient A1 Patient B1 P (OS) <> AMC v non-AMC Hospital 4* v 1* Specialty Surgeon P, Busy Procedure %C Situation R v Em

For Overlapping Cases and an Attending’s Absence Training requires it. A resident cannot achieve independence with an attending present. Safety is not compromised. Attending can judge a resident’s progression to independent competence. Efficiency demands it. Absence from OR is essential to efficient use of a skilled surgeon’s time.

Benefit of Overlapping Surgery Surgery, esp start and finish, is often routine, simple, time consuming patient intro, anesthesia induction, positioning, sterile prep, set up, localization, initial exposure; hemostasis, closure, awakening Often, the primary surgeon’s presence is simply not needed Absence from OR is essential to efficient use of a skilled surgeon’s time. promoted by hospital’s desire to keep a productive S busy Altruistic exercise one’s skill to benefit more patients Mercenary salary (hospital pressure), promotion, prominence, ego N.B. both presume the surgeon is uniquely skilled – very rare

Against Overlapping Cases and an Attending’s Absence Efficiency may not suffer. OR efficiency, improved by the A’s presence, supersedes the A’s efficiency. Training does not require it. An A’s presence does not preclude a R’s progression to independence. Safety may be affected. Safety must be proven by more than subjective judgment.

Risks of Overlapping Surgery Although surgeons try to schedule cases so as to avoid concurrence, Attending Absence during CPs can still occur Patients are scheduled far in advance and asynchronously Cases proceed unpredictably (anesthesia, unique anatomy) Resident assignments and abilities vary Critical events may occur unexpectedly (“routine opening”) Dilemma : when Attending is unavailable Assistants stand idly prolonging the case increasing CX DVT/PE, pneumonia, wound infection OR Assistants proceed to CPs for which they are unqualified. Neither is safe

Risks of Overlapping Surgery Evidence is scant MGH reviewed of 25 concurrent surgeries that had complications and found none attributable to double booking The Doctors Company found no mention of concurrent surgery as a factor in 7,330 malpractice cases Zhang et al. J of Bone and Joint Surgery, 2016 No difference in outcomes of 3,640 overlapping and non-overlapping operations wrt procedure time, time in the OR, complication rate. Yount et al. AM American Association of Thoracic Surgery, 2015 Attendings’ performing simultaneous cardiac operations in academic MCs does not increase case duration or adversely affect patient outcomes. Need EMR-enabled correlations of extent of attending involvement in hypothesized CPs with patient outcome

My View Hierarchy : Safety > Training > Efficiency Safety is the paramount consideration. Learning curve for skilled procedures any part is likely safer with the A present Caveat: added benefit may be minimal

Training is likely enhanced by an A’s presence Caveat: R competence may abrogate the need for more training; optimal outcome may be achieved by a less experienced resident operating alone if autonomy is granted only as earned by skill. This requires accurate judgment of task complexity & R aptitude. Most data suggest that attendings are getting this right.

Efficiency is a tertiary consideration (hospital’s may >; A’s will <) Having Rs assist in non-op care more than compensates The Attending should be present when outcome is at stake or training opportunities exist.

Overarching Consideration Patients expect the attending to be involved throughout the case. JAMA Surgery : only 18% of patients would consent to a resident “acting as operating surgeon with or without staff observation.” That patients don’t know implies patient consent is not truly informed. The participants and their roles are not adequately explained? The potential absence of the primary surgeon is not explicit? Consent = Salient issue of medical and lay response to Spotlight series As long as patients feel inadequately informed, Malpractice suits will multiply Regulation will proliferate Patient-physician trust will be eroded.

Trust is the foundation of the therapeutic relationship. it is the glue of the sacred bond between patient and physician; all other considerations derive from it. This trust is mutual: The belief by the patient that if he/she puts his/her life in our hands, we will do our best to ensure an optimal outcome; and the assumption that if we do give our best, we will not be blamed for failure.

This mutual trust emboldens both patient and physician. It fosters in patients the courage to allow us to undertake needed surgery; and it encourages us to risk failure and to face the criticism from ourselves and others that failure may bring. Warranting a patient’s trust is essential to a physician; that we act in trustworthy fashion both gives our efforts meaning (we serve others in a way that warrants trust and gratitude) and allows tolerance for less than optimal outcomes (we can reconcile with failure only if it has occurred despite our best effort).

Informed Consent = tangible manifestation of this trust I am your surgeon; I will do my very best to achieve an optimal outcome for you. I will be highly engaged throughout your surgery; “I will be scrubbed and actively involved in the critical parts of your surgery, but for non-critical parts of your operation which my resident will perform, I may be operating in another room or in my office, but I (or my faculty partner) will be able to return immediately to your room if needed.” I also have an obligation to train future surgeons for the benefit of future patients – just as I was trained for your benefit. And I try to be efficient with hospital and societal resources and my time so that as many patients as possible may have the same quality of care that you hope to receive.

So, depending on the part of the case and the experience and ability of the other surgeon(s) working with me, My engagement may take different forms: I am scrubbed and perform the surgery I am scrubbed and assist another surgeon I am in the room, not scrubbed, but supervise the operation I am not in the room but direct the other surgeon by planning of your case and my previous training of the other surgeon. .

Regardless, I vow to you that my choice in this regard will be guided by my desire to achieve the best possible outcome for you and that this will not be compromised by other considerations.

Surgeons’ Progression

I: Fear to Action

II: Introspection to Analysis

III: Resolution

to Principled Practice

Surgery

Informed Consent

Mutual Trust