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Concurrent surgery: No evidence care is compromised
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Recently, Massachusetts General Hospital was the subject of an investigative report by The Boston Globe for its practice of concurrent surgery in the hospital’s department of orthopedics. The accusations in the report, which have been denied by the medical institution, are heartbreaking. The report suggests patients had surgery by one physician while another patient was also having surgery by the same physician and, in some cases, the outcome was disastrous.
Although complications can happen with any surgery, the report’s insinuation is the primary surgeon may have not been involved in the part of the surgery that resulted in a severe complication. Furthermore, because this is an academic medical center, additional suspicions included that procedures were performed by residents and fellows without proper supervision of attending surgeons.
The report has led to further investigation by the hospital, medical staff and other agencies, such as The Joint Commission, the Massachusetts Department of Public Health and the American College of Surgeons.
Multi-faceted issue
The issue of concurrent surgery has many facets to consider. Allowing surgeons to schedule cases in two ORs is a frequent practice, both in academic medical centers and in community hospitals. The purpose includes improved efficiency in the use of OR staff and the surgeon’s supporting staff. In many ORs, the time from when the surgeon is done with one surgical procedure until he or she is needed for the next surgery in the same OR provides ample time to safely and competently perform another surgery in another room.
Anthony A. Romeo
The practice is primarily used by the busiest surgeons who have many patients who desire their care. Having two ORs allows for surgeons to at least double the number of surgeries they are capable of performing in a single OR day, allowing them to care for more patients with their skilled hands.
In busy medical centers, many people are involved in the patient care at every step of the OR day. Each step requires added time and while it may be inefficient, it still provides great patient care. There is no reason the attending surgeon — the surgeon of record for the procedure — needs to be present for much of the patient preparation and conclusion of the care process, including awakening the patient and, when ready, moving him or her to the recovery room.
Hospitals and medical groups want to provide support services and staff for their busiest and most productive surgeons. Staffing and providing two ORs allows their best surgeons to treat more patients. Numerous published peer-reviewed studies have shown decreased complications and improved outcomes in the hands of surgeons who perform high volumes of surgery.
Role of supervision
One concern of the report was that the participation of medical students, residents and fellows had an adverse effect on outcome. In the ideal situation, the attending surgeon provides supervision in a manner that results in the same outcome whether residents and fellows are used. In a recent publication that reviewed a national database of patients undergoing shoulder arthroplasty, there was no difference in overall outcome in cases performed with or without the use of residents.
There is also a suspicion that having two ORs available at teaching hospitals implies less involvement by attending surgeons when compared with two-room availability at community hospitals. Some orthopedic surgeons in the United States will perform more than 1,000 surgeries per year due to an efficient and extensive team who works with them on a regular basis. On some days, the surgeons may have cases scheduled in three ORs to be most efficient with resources and personnel. Because there are no residents or fellows, the attending physician is the only person who will perform any of the essential parts of the surgical procedure, despite the hospital schedule reflecting the use of three ORs. The surgical procedures may have overlapping time on the surgical schedule, but the surgeon is operating in alternating rooms and the procedures are performed in sequence as there is only one possible surgeon.
Transparency needed
Many patients do not know orthopedic surgeons are able to schedule cases in two separate ORs. However, the issue of concurrently scheduled ORs by a single surgeon is becoming public knowledge. This often raises patients’ concerns about who is performing the procedure.
We need to be transparent with the care of our patients. Currently, disclosure to our patients is not required if an orthopedic surgeon desires to run two ORs simultaneously. However when asked, surgeons should be able to clearly explain to patients how they manage this responsibility. If a surgeon believes he or she cannot openly share with patients the way the OR runs, then the overall process should be reviewed for true consent, as well as following one’s own ethical and moral standards.
Documentation
If surgeons are present during the part of the surgery that affects outcome and there is plenty of time before they are needed for the next case in the same OR, then they should be able to perform another procedure in another OR. Electronic medical record systems will show a substantial overlap in cases, and an “appearance” of concurrent and possibly poorly supervised surgery is likely. Therefore, documentation of the surgeon’s presence during the essential components of the procedure is critical.
Most commonly, the OR staff documents components of the procedure, such as the time when patients are in the OR, when incisions are made and when patients are out of the OR. This information is used in a variety of ways, including allowing the hospital to bill for the used OR time. However, it inaccurately defines the time the surgeon of record is directly involved in the care of the patient, which may be a small fraction of the time the patient is in the OR, especially in academic medical centers where efficient use of time has not been a priority, and one of many reasons why surgeons prefer ambulatory surgery centers.
Surgeons should document their start time and the time to completion of the essential components of the procedure. This does not need to include every aspect of the care provided in the OR, such as positioning of the patient, organizing the equipment used during the case, putting on the dressing at the end of the procedure or moving the patient to the transport bed. Although controversial, the surgical incision, initial steps of the surgical procedure and wound closure can be competently and beautifully performed by well-trained and supervised surgeons in training.
Efficiency in the OR
The practice of scheduling surgical cases in two ORs for one surgeon is an ideal method for improving the efficiency and use of OR resources while providing excellent patient care. Some surgeons perform more than 1,000 surgeries per year, yet are not at major medical centers with the added workforce of medical students, residents and fellows. They accomplish this task by having efficient ORs, consistent OR staff who know the surgeon’s preferences, as well as surgical technicians, physician assistants and OR assistants who can accomplish the non-essential parts of the procedure. By having two ORs or sometimes three, surgeons can consistently work throughout the day to complete 10 or more surgical procedures. The literature indicates that high volume surgeons frequently have high patient satisfaction and outcome scores.
The terminology for scheduling cases in two ORs is unfavorable to the orthopedic surgeon. While the ORs run concurrently based on the hospital’s schedule and documentation, the valuable time the surgeon is present and performs essential components of the procedure is accomplished by alternating between two ORs throughout the day. In an ideal situation, the essential part of each procedure is performed in sequence, alternating between ORs, not simultaneously or concurrently being performed by someone other than the primary surgeon, unless proper consent has been achieved preoperatively. We should work toward a clear understanding and distinction that while the hospital may document concurrent ORs on schedules, our efforts are alternated between ORs so the surgeon of record is present during the essential components of every procedure.
- References:
- Cvetanovich GL, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2015.03.023.
- Hammond JW, et al. J Bone Joint Surg Am. 2003;85:2318-2324.
- http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/?p1=Clash_Landing_to-story
- Scott DJ, et al. Orthop J Sports Med. 2015;doi:10.1177/2325967115574476.
- Swart E, et al. Clin Orthop Relat Res. 2015;doi:10.1007/s11999-015-4494-4.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
Disclosures: Romeo reports he receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.