A previous article in the Boston Globe a few years ago described the story of a patient who suffered a serious complication associated with a spine operation.1 Although the article raised many issues, there are 2 central ethical questions that we believe require attention. 1) Is there anything inherently unethical in a single surgeon having 2 patients in operating rooms at the same time (overlapping operations)? 2) Should surgeons always disclose overlapping cases to patients?
To answer these 2 questions, it is important to consider the interaction between the surgeon and the patient preoperatively. Some commentators have referred to this discussion as a form of a contract between the surgeon and the patient, while others characterize it as an agreement. The surgeon discloses the risks, benefits, and alternatives to the proposed procedure to the patient. The patient and surgeon also form a relationship, in which the patient trusts the surgeon to deliver/coordinate/supervise their care. The informed consent document is a written acknowledgement of the patient's understanding of what has been proposed, and the patient's willingness to undergo the procedure with its attendant possible risks and benefits as described by their surgeon. The surgeon, by agreeing to perform the operation, is making an implicit promise to do everything that he or she can to ensure that the patient attains the best possible outcome.
Is the agreement to perform surgery upon a patient an implied promise that the surgeon will be performing all aspects of the operation? We believe that it is not. In a well-functioning operating room, as in most well-functioning systems, there is a division of labor such that different people perform specific functions. Perioperative care is so complex that this kind of division of labor and specialization produces more efficient, economical, and better care. The delegation of tasks to others is no longer limited to the delegation of anesthesia to anesthesia providers, nursing activities to nurses, or the operation of radiology equipment to technologists, it can often include delegating portions of the procedure itself to other members of the team. In the case of a heart valve replacement, the opening and closing of the chest may be performed as well or better by a surgical fellow or a physician's assistant under the supervision of the attending surgeon. In general, strategies that maximize the use of the narrow expertise of specialist surgeons will produce better outcomes for a larger number of patients. In such systems, the attending surgeon performs those aspects of the procedure that demand his or her high levels of expertise. In such systems, the attending surgeon has the responsibility to build and maintain a team that delivers the highest levels of care to their patients at all phases of the operation.
What is the surgeon's fiduciary responsibility? It is to surrender their own interests and to do everything in their power to produce the very best possible outcome for the patient. This includes the delegation of all tasks that might be accomplished by someone more expert in that domain to such a person. Such tasks might include assembling and organizing the instruments for a procedure, the setup of the room for a procedure, preparing and positioning the patient, and the administration of anesthesia for the procedure. Division of labor and specialization in this manner is a characteristic of all mature, highly functioning industries that attain high levels of performance. It is also the surgeon's fiduciary responsibility to their patient to be as experienced and expert as possible in performing those portions of the procedure that only they can perform. To the extent that performing overlapping procedures dramatically increases the rate at which a surgeon acquires and maintains this expertise, overlapping surgery is aligned with the surgeon's fiduciary responsibility to each of their patients, and empowers them to be more effective agents for their future patients.
Seen in this light, it becomes apparent that during some surgical procedures the attending surgeon's presence and attention may not be required for significant periods of time in the operating room, including the induction of anesthesia, the placement of catheters and invasive monitors, the positioning of the patient, and the preparation of the patient's skin. A surgeon might appropriately engage in any number of other activities while these portions of the procedure are taking place, including generating care for other patients, talking to a patient or their family in a recovery area, or following up on the care of other patients. When should surgeons be present? Whenever, in their best judgment, they need to be, which will vary for every procedure and every patient.
How are things different for the attending surgeon as compared with the attending anesthesiologist? The surgeon has formed a relationship with the patient prior to the day of their procedure; in most instances the anesthesiologist has not. It is the surgeon who has obtained the trust of the patient that has led to the patient coming to the hospital for the operation. Nevertheless, the activities of the attending anesthesiologist are as critical to the patient having a safe and effective operation as are the attending surgeon's activities. Should there be concern about an attending anesthesiologist having patients asleep in 2 operating rooms at the same time? We believe that the answer is, “No.” It may be that many patients are not aware of this practice. Nevertheless, we believe that the critical portions of a general anesthetic are more clearly understandable to patients than are the critical portions of a surgical procedure. Patients readily accept that going to sleep and waking up are the most worrisome aspects of a general anesthetic. They seem, therefore, to more readily accept that during other times, the attending anesthesiologist may not be present, but will delegate care to an appropriately trained member of the anesthesia team.
Should surgeons always disclose planned overlapping procedures to patients? In elective situations, we would answer, “Yes.” Nevertheless, we believe that in a carefully coordinated system where the surgery and anesthesia teams work together to ensure that operations start and proceed in a manner that allows the attending surgeon to be present and fully attentive for the critical portions of the operation for each patient, the presence of another patient in another operating room does not violate the implicit promise of the surgeon to do everything possible to ensure that the patient has an optimal outcome from the procedure. Certainly, there is no reason to keep such operating room schedules secret. But as long as the surgeon can maintain full focus on each individual patient during the critical portions of the operation, the surgeon has discharged his or her responsibilities to the patient. If unforeseen circumstances arise such that the attending surgeon is needed for critical portions of both operations at the same time, there must be another attending surgeon immediately available to take over one of the cases. In such unplanned circumstances, the patient should certainly be told of the role of the second surgeon and the reason why the second surgeon was called.
The delivery of modern surgical care entails the division and coordination of labor over time and space across care-givers with highly specialized expertise. Patients receive exceptional care throughout their operation, even when the attending surgeon or the attending anesthesiologist is not present in the operating room. Explaining this division of labor to patients may be time consuming, but if it eliminates the possibility of even the appearance of patients being misled by their caregivers, the time will be worth the effort.
1. Abelson J, Saltzman J, Kowalczyk L, et al. Clash in the name of care. The Boston Globe
. October 25, 2015. Available at: https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/
. Accessed September 1, 2019.