Experts Discuss Surgical Timing, Technique

SAN DIEGO—Widespread publicity about surgeons being involved in more than one surgery at once, touched off by a Boston Globe investigation late last year, has prompted Congressional scrutiny and caused the surgical field to closely examine whether or not the practice is carried out properly and leads to favorable outcomes. Panelists at this year’s Annual Meeting of the American Academy of Otolaryngology shared their own experiences and discussed how to avoid both medical errors and ethical lapses.

Finding Balance

Brian Nussenbaum, MD, chief of head and neck surgical oncology and vice chair for clinical affairs at Washington University in St. Louis, Mo., said the topic ties together several issues that can sometimes be hard to balance. “Overlapping surgeries stand at the crossroads of ethics and informed consent, patient safety, surgical education, effectiveness of care, efficiency of care, and timeliness of care,” he said.

His hospital, Barnes-Jewish in St. Louis, Mo., was one of the centers asked to respond to a request for records on overlapping surgeries from U.S. Senator Orrin Hatch of Utah. The institution’s records showed that, over a 15-month period, 6% of all otolaryngology surgeries overlapped, and six of the seven surgeons for whom more than 6% of surgeries overlapped were head and neck surgeons.

In April 2016, the American College of Surgeons (ACS) published guidelines defining different types of surgery that occur at the same time. “Concurrent” surgeries are defined as those in which “critical or key components” for which the primary surgeon is responsible are happening at the same time. “Overlapping” surgeries are those in which the primary surgeon starts a new operation after finishing the critical parts of another surgery, but before that first surgery is completed. The ACS position is that concurrent surgeries are “not appropriate,” and that patients involved in overlapping surgeries must be informed about the primary surgeon’s whereabouts.

In June, Dr. Nussenbaum said, Barnes-Jewish adopted a policy stating that overlapping surgery requires documenting a conversation with the patient in advance, that all critical parts of a surgery have to be completed before the surgeon moves on to another one, and that any emergency or extenuating situation resulting in unplanned overlapping surgery must be discussed with the patient afterward.

Varied Opinions

David Cognetti, MD, associate professor of otolaryngology-head and neck surgery and co-director of the Jefferson Center for Head and Neck Surgery at Thomas Jefferson University in Philadelphia, presented the results of an AAO survey of its members that showed that 60% of the 907 surgeons who responded said that “multiple-room surgeries,” as the survey described them, occurred at their centers. But 40% said they didn’t know if their center had a policy covering the rules for the practice.

Approximately 40% of the respondents said they perform multiple-room surgeries themselves. Among those who don’t, the most commonly cited reason was that they didn’t feel comfortable doing so. Among those who do perform such surgeries, 40% said they do so weekly. Furthermore, half of those who said they engaged in the practice also stated that they didn’t routinely inform patients ahead of time.

More than 70% of respondents said that more procedures would be delayed if multiple-room surgeries weren’t allowed. Approximately 30% said that patient safety would be improved if such surgeries weren’t allowed, and 10% said they would be detrimental to patient safety. More than 60% of respondents said residency training would suffer if the practice was not allowed.

The survey also found that a surgeon who performs multiple-room surgeries is more likely to think patient safety would be worsened and that wait times would lengthen if the practice were disallowed.

Respondents could also make remarks on the practice of overlapping surgeries. “I can tell you, reading through the comments, there are many varied opinions and many of them are very passionate,” Dr. Cognetti said.

One respondent said that patient safety isn’t compromised, that residents are allowed more operating time, and that “expert surgical care is maintained by the responsible surgeon.” Another said, “No one can be two places at once. Accept it. The patient believes you are their physician and you are caring for that person—but you are not.”

Effectiveness in Overlapping Surgeries

In a study conducted at the University of Alabama at Birmingham (UAB) and Oregon Health and Science University, researchers looking at microvascular free tissue transfer procedures for reconstruction of head and neck defects found no statistical difference in several areas between non-overlapping and overlapping procedures. Overlapping procedures were defined as those in which they both had a first start or the second operation began before the first was finished, with the attending surgeon not performing the critical components concurrently.

In the study, which involved 1,315 surgeries, there was no difference in complication rate, in length of stay, or in free-flap survival rate. There was a significant difference in the amount of anesthesia time, with patients involved in overlapping procedures receiving an average of 21 more minutes of anesthesia.

“We found that overlapping operations can be performed [as] effectively and with equivalent quality as those that were non overlapping,” said Larissa Sweeney, MD, a resident at UAB who presented the findings. “We advocate the continued practice of surgeons conducting overlapping operations.”

Overlapping surgeries stand at the crossroads of ethics and informed consent, patient safety, surgical education, effectiveness of care, efficiency of care, and timeliness of care.— Brian Nussenbaum, MD

Ethical Considerations

Alexander Langerman, MD, a head and neck surgeon and clinical medical ethicist at Vanderbilt University in Nashville who is researching the practice, said that while medicine has always involved delegation, the difference here is that the patient is unable to actively participate in his or her own care during surgery.

But there are ethical considerations on the other side as well—many patients need surgery urgently. “As a head and neck cancer surgeon, I see lots of patients in clinic who need to get in the operating room,” said Dr. Langerman. “They’re sort of this ticking time bomb with their cancer, and we want to get them cared for. So it’s always a struggle: How can I care for as many patients as possible?”

He is working on a study on how to assess what it means for a step in a surgery to be “critical,” requiring the attending surgeon to be there. Until hard data exists, “attending judgment is the best we have,” he said. He underscored the importance of getting to know your trainees, leaving wiggle room in your schedule, and being honest with patients.

Influence of Increased Regulation

James Denneny, MD, executive vice president of the AAO-HNS, who stressed that he was speaking personally and not on behalf of the Academy or any other organization, said that the issue of overlapping surgeries is more important today than it was 20 years ago because of increased regulation, the push for quality and value, and other factors.

Risks associated with the practice include added stress for the physician, the possibility of unexpected problems in one or both rooms, the difficulty of accurate record keeping at the end of a long day of overlapping surgeries, physician fatigue, and potential confusion while moving from case to case. “If you’re doing 20 or 30 cases in a morning, it’s difficult sometimes to remember who’s who,” he said. “When I’m a patient, I want to know you know what my problem is.”

Patients are concerned that they’re paying for a particular surgeon to be there from start to finish, that the surgeon may not be available if something goes wrong, and that rushing can lead to mistakes and an increased risk of infection, especially if a surgeon isn’t careful about washing, said Dr. Denneny. If a surgeon chooses to perform overlapping surgeries, he added, the process should be transparent all the way through, the needs of a patient need to be evaluated individually, a qualified back-up should be identified in advance, and all demographics should be treated the same.

---

Thomas Collins is a freelance medical writer based in Florida.