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Editorial

Overlapping Surgery – Honoring Our Patients' Preferences

Leopold, Seth S., MD

Clinical Orthopaedics and Related Research®: June 2018 - Volume 476 - Issue 6 - p 1133–1134
doi: 10.1097/01.blo.0000533622.11263.d1
REGULAR FEATURES

S. S. Leopold, Editor-In-Chief, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA

S.S. Leopold MD, Clinical Orthopaedics and Related Research® 1600 Spruce Street Philadelphia, PA, 19013 USA Email: sleopold@clinorthop.org

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Received March 21, 2018

Accepted March 26, 2018

Following a scathing exposé in the Boston Globe about surgeons running concurrent surgical procedures in two different operating rooms [1]—a story that surprised no one who performs orthopaedic surgery, but mortified some in the lay public—the U.S. Senate took up the topic. Its work product was a 22-page, single-spaced document about overlapping and concurrent surgery whose recommendations are clear enough from its subtitle: “Additional Measures Warranted” [12].

This was not an instance of complete failure of our profession to police itself. The American College of Surgeons (ACS) [2] had articulated standards on this topic that the American Academy of Orthopaedic Surgeons (AAOS) also embraced [11]. However, the Senate’s impression was that only after the story in the Globe did they observe “a shift in attitudes among many organizations” to address the problem in a substantive way [12]. I believe their impression is largely correct: I observed more changes to medical-centers’ policies related to overlapping surgery in the months following the Globe article than I had in the years prior to it.

I should note that the investigative piece in the Globe pertained to elective surgery, not emergency surgery, and not to surgery in the setting of mass-casualty events like the Boston Marathon bombing [6] in which different rules might well apply. So, I will constrain my comments here to the topic of elective surgery. For purposes of this conversation, I consider concurrent surgery to mean the critical portions of two or more procedures occurring in different rooms at once under the supervision of the same attending surgeon. By contrast, overlapping surgery involves the same surgeon supervising two procedures in different rooms, in which the critical portions of those procedures are staggered in time.

The Center for Medicare & Medicaid Services (CMS) prohibits the same surgeon from billing for concurrent surgical procedures in two rooms at teaching hospitals, and restricts how overlapping procedures may be performed. Importantly, though, CMS’s rules do not apply outside teaching settings [12]. Both the AAOS and the ACS consider concurrent surgery to be inappropriate, but allow for overlapping surgery in certain situations [2, 11]. Numerous individual surgeons—including some in the opinion pages of Clinical Orthopaedics and Related Research ® [4]—have expressed diverse opinions about what sorts of regulations, oversight, and research ought to guide us in these settings. Others [8] have used the classic principles of bioethics [3] to derive specific recommendations for the AAOS, hospitals, surgical educators, and practicing surgeons. A large part of one of those essays, appropriately, focused on the topic of transparency during the informed-consent process [8].

Unfortunately, American surgeons may not adequately disclose enough about their approaches to overlapping and concurrent surgical procedures for patients to fully and fairly provide consent [10]. Certainly, the Senate’s investigation arrived at this conclusion [12], and the few objective data we have on patients’ perceptions seem to confirm it. It appears from those data that few patients know that surgeons sometimes perform overlapping or concurrent surgery on two patients at once, a large majority disapproved of the practice, and the clear majority of them—more than 90%—felt that should it occur, it should be disclosed [7]. In another study, fewer than one in three patients would give consent to a proposed procedure in which a staff surgeon assisted a resident, and perhaps more importantly, more than 40% would not consent to a procedure in which that resident assisted an attending surgeon [9].

It is for this reason, and this reason alone, that I say that the topic is not really a difficult one. Leaving aside federal regulations, standards of professionalism as set by our national societies, hospital-level flexibility or inflexibility on what constitutes the “critical portion” of a surgical procedure, and even classical bioethics (as I fully intend to do), the issue is this: Where we can, we should provide care that is consistent with the values our patients express.

And we can do so on this topic, easily. Concurrent surgery, wherein important parts of two patients’ procedures take place at the same time in different rooms, should become part of surgical history. That practice violates a fundamental commitment a surgeon makes when (s)he agrees to care for a patient. If we want to make assumptions about patients’ values as it concerns overlapping surgery, the best evidence we have—scanty though it may be—suggests most patients prefer to be the devotees of our undivided attention [7]. Should we plan not to honor that preference, we should disclose this fact in advance, as part of a thoughtful consent process that explicitly describes our workflows. I suspect this is how most of us would want to be treated.

But perhaps not. And because of that, it’s probably best not to assume. I suspect that many patients’ viewpoints on this complicated but important topic would change, or at least become more nuanced, if surgeons dealt with it openly. For that reason, it seems only fair that surgeons who perform overlapping surgery ask their patients whether they are comfortable with the arrangement, and reassure them that the surgeon will be present for the key parts of the operation and will be available (or have a partner available) for the balance of the work.

The only approach that does not seem right is to surmise that patients are happy to be in one room while the surgeon is in another, as they probably are not [7, 9].

Notwithstanding the fact that CMS’s standards apply only to teaching hospitals, it seems to me that the ethical imperatives involved here seem equally applicable to private-practice settings as to teaching hospitals, whether in the United States or in other countries. It really comes down to honoring each patient’s preferences, which is the standard to which we all ought to hold ourselves.

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References

1. Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care. Boston Globe. October 25, 2015. Available at: https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/ Accessed March 10, 2017.
2. American College of Surgeons. Statements on principles (revised April 12, 2016). Available at: https://www.facs.org/about-acs/statements/stonprin. Accessed March 19, 2018.
3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics (7th ed). New York, NY: Oxford University Press; 2012.
4. Bernstein J. Not the Last Word: Two patients, two operating rooms, one surgeon—Does the math add up? Clin Orthop Relat Res. 2016;474:2094–2099.
5. Boston Globe. Clash in the name of care: The emails. Available at: https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/e-mails/. Accessed March 19, 2018.
    6. Gebhardt MC. Patriots’ Day at the Boston Marathon. Clin Orthop Relat Res. 2013;471:2045–2046.
    7. Kent M, Whyte R, Fleishman A, Tomich D, Forrow L, Rodrigue. Public perceptions of overlapping surgery. J Am Coll Surg. 2017;224:771–778e4.
    8. Levin PE, Moon D, Payne DE. Overlapping and concurrent surgery: A professional and ethical analysis. J Bone Joint Surg Am. 2017;99:2045–2050.
    9. Porta CR, Sebesta JA, Brown TA, Steele SR, Martin MJ. Routine disclosure of trainee participation and its effect on patient willingness and consent rates. Arch Surg. 2012;147:57–62.
    10. Rickert J. A patient-centered solution to simultaneous surgery. Available at: https://www.healthaffairs.org/do/10.1377/hblog20160614.055355/full/. Accessed March 19, 2018.
    11. Tingle C. Concurrent surgery: Defining and implementing a safe practice. Orthopedics Today. Available at https://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedics-today/%7B2550f2a9-f03a-4d1c-b9f3-0dc7d7c36d02%7D/concurrent-surgery-defining-and-implementing-a-safe-practice. Accessed on March 19, 2018.
    12. United States Senate Finance Committee. Concurrent and overlapping surgeries: Additional measures warranted. Available at: https://www.finance.senate.gov/download/finance-concurrent-surgeries-report. Accessed March 20, 2018.
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