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Patient care must be the compass that guides the surgeon’s decisions
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Late last year, The Boston Globe published a “Spotlight Team Report” on events surrounding concurrent surgeries at Massachusetts General Hospital that resulted in poor outcomes. While there are inherent risks to any surgical procedure, the report has brought into question the practice of surgeons running two cases in parallel.
Subsequent to the publication of the article has been an increased awareness of concurrent surgery and interest in the ethical and moral obligations surgeons have to patients at the time of surgery. Specifically, the issue of whether concurrent surgery breaches any of these obligations to patients.
Risk and efficiency
At its most basic, concurrent surgery refers to surgeons booking two surgical cases in two separate ORs at a similar or same time. Many experienced senior surgeons will also stagger start times between the two ORs as to be available during the critical times that have the greatest impact on outcome.
As Alexander Langerman, MD, SM, stated in his JAMA Viewpoint, concurrent surgeries can run by several different models, each one balancing different levels of risk and efficiency. In an ideal situation, ORs run efficiently, operations run smoothly and the senior surgeon is present for the critical portions of all cases. Unfortunately, there are times when surgery does not go smoothly, ORs run inefficiently, the senior surgeon is unavailable for critical portions of the case and patients may have an adverse result. At some teaching institutions, the senior surgeon may delegate critical portions of the case to fellows or residents on a consistent basis, but the patient is usually unaware of this arrangement even if it is included in the written preoperative consent.
Ethical standards
In addition to general ethical standards, the surgeon-patient relationship is different than other physician-patient relationships by the nature of what a surgeon does. It is difficult to think of a more vulnerable position than that of a patient on day of surgery.
One obligation surgeons have to patients on the day of surgery is to provide accurate information about the indications, risks and potential benefits of the scheduled procedure. Unless the surgery is emergent, this should be a reiteration of what was previously discussed in the surgeon’s office. In addition, one could argue surgeons have the ethical obligation to make data-driven decisions. If this is not possible, then decisions should be made in line with what their training and expertise tells them is in the patients’ best medical interest.
Surgeons have to be committed to provide the best care possible on that particular day for that specific patient. It is the surgeon’s responsibility to make sure everyone providing care does so to the best of their abilities and to ensure care is provided in a secure, sterile and optimized environment. Surgeons should have informed the patient of how the operative procedure will be accomplished by the surgeon and any staff who will participate in the procedure.
When the patient is on the operating table, the surgeon should be committed to completing the operation in the safest and most efficacious way possible. Once the patient has recovered from anesthesia, it is the surgeon’s responsibility to share findings of the operation and expected outcomes in a clear and honest way patients can understand. Patients should be given postoperative instructions and discharged to the most appropriate location given the complexity of the surgery and possible complications that may arise during the early postoperative period.
Competing obligations
The surgeon’s primary interest and obligation should be to the welfare of the patient. The patient puts trust in the surgeon that he or she will make the best effort to ensure a successful surgery. As surgeons have a responsibility to take excellent care of patients, teaching surgeons also have the responsibility to train the next generation of surgeons. It is a delicate balance that requires giving trainees not just time to observe the craft of surgery, but also autonomous time to practice and improve skills.
Through experience, trainee surgeons learn by practicing and understanding the nuances of surgeries. Senior surgeons should grant autonomy in a safe and secure environment during training. Surgeon educators often suggest one of the best ways to grant this important and carefully monitored autonomy for surgeon trainees is to perform concurrent surgeries. However, this does not release the senior surgeon from ethical and moral obligations to provide the best care possible to patients.
Benefits and pitfalls
Running concurrent ORs provides busy surgeons the opportunity to perform more operations on a given day. This increases the efficiency of hospitals, allows surgeons to perform more surgeries and provides more patients access to care in an efficient manner. It also provides teaching surgeons with a calibrated way of training future surgeons.
Anthony A. Romeo
A pitfall is that rarely is a surgery a perfect event. Intraoperative decision-making is critical to outcomes for many procedures and complications happen even for the best surgeons. If there is difficulty during one case, the surgeon can delay the start of the next case when the procedures are staggered, but not if they are performed at the same time.
However, a larger issue is patients are generally unaware a senior surgeon runs concurrent ORs and may not be present for the entirety of the case. The root of this issue may be consent. The surgeon responsible for the procedure — the person patients have placed their trust in — should be capable of describing exactly how the procedure will be managed by all staff. The desire to keep the management of the OR hidden from the patient is a sentinel event that strongly suggests the surgeon has not met moral and ethical responsibilities for patients.
Balance is needed
Most training institutions are required to explain to patients in writing that by choosing to be cared for at a teaching institution, they have consented to have medical students, residents and fellows take part in their care. Patients can opt out and request no trainees be a part of their care, but usually this requires a specific request. Similarly, if another surgeon is going to be involved in the surgical case, then the other surgeon’s name also should be included on the consent form and the patient should be made aware to fully understand it might not always be the attending surgeon who performs the procedure.
Although management of concurrent surgical cases needs to be in balance with all interests of the surgical team, ultimately care of the patient must be the compass that guides the senior surgeon’s decisions during an operating day. This is not a responsibility that should be delegated to anyone other than the senior surgeon. Surgeons who are given the privilege of having two available ORs should plan their case order and start times to minimize the chance of harm to patients. They also should be in charge of the decisions regarding who will perform the various aspects of each procedure. Patients also must be informed.
It is not enough to suggest that because there is language in the consent form that informs patients other surgeons will be involved in the care, the patient completely understands and accepts the senior surgeon’s practice. This topic needs to be discussed directly with patients. If surgeons are uncomfortable discussing the issue, they should re-examine priorities to ensure they meet the moral and ethical responsibilities of a competent patient-centric surgeon. When concurrent surgeries are performed in a thoughtful and careful manner, they can be beneficial to all involved, including trainee surgeons and patients.
- Reference:
- http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/?p1=Clash_Story_to-landing
- Langerman A. JAMA Surg. 2016;doi:10.1001/jamasurg.2016.0511.
- For more information:
- M. Michael Khair, MD, can be reached at W.B. Memorial Carrell Clinic, 9301 North Central Expy., Suite 400, Dallas, TX 75231; email: mkhair@wbcarrellclinic.com.
- 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: Khair reports no relevant financial disclosures. Romeo reports he receives royalties, is on the speaker’s bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.