Sure to be a complex controversy: “Concurrent surgery” (Boston Globe Spotlight series)

Screen capture of story from Globe home pageAh, the world of social media. This morning’s Boston Globe “Spotlight” investigative team (which won a Pulitzer in 2003) has this, citing local superstar hospitals Massachusetts General and its sister hospital, Brigham & Women’s. Within an hour the discussion got so meaty that I knew we had to move it here, because Facebook threads basically disappear in a week, and this needs to last. It has such implications for patient and family engagement, starting with just being aware of the realities of hospital business and how that affects the staff who will treat your family.

Should a surgeon run two operations at once, moving from room to room in the times when s/he isn’t needed in the other OR? It’s a splendid example of a complicated question in medicine, with (IMO) no clear answer, so don’t jump to a conclusion without reading and thinking (including the discussion pasted into this post).

The issue involves evidence, ethics, statistics, best use of resources, and an inescapable reality (as I’ve said for years in speeches): we all need to be honest that it’s dangerous to cut people open. In the featured case here, no one has any idea if the patient’s disastrous oops was related to the surgeon doing two cases at the same time.

There will be much fighting about this I’m sure, in the coming weeks. Here are the first comments from Facebook, pasted in with permission.

Hari Khalsa, nurse practitioner and patient advocate: This is why informed consent is so important. I have my clients cross out that the surgeon can designate a resident or fellow to do the surgery. They write in bold “only the surgeon”. This is a legal document.

Then an exchange between two of the smartest people I know anywhere, Peter Schmidt (head of the Parkinson’s Foundation, not an MD) and Henry Feldman MD of Beth Israel Deaconess, who I can only describe after following him on FB for years as superhuman for his breadth of knowledge, skills, and range of clinical experience. Immediately they illustrated how complex this is:

Peter Schmidt: I did my fellowship in an orthopedic hospital, HS. We didn’t allow concurrent surgery, the place down the street, LH, did. The main reason HS gave for restricting concurrent surgery (surgeons wanted it and sometimes left to get it) was that we had trainees in every OR. Trainees require education and supervision. We really didn’t think of this as a patient safety issue, because no single individual was responsible for patient safety.

At LH, when a surgeon was allowed concurrent surgery, the surgeries were staggered so that the stuff the surgeon did not overlap but the stuff residents and fellows did. When bad stuff happens, it’s very easy to blame things on things like concurrent surgery or things like that. However, there is good science (I am doing some of this) to show that the very best doctors deliver the best outcomes. Would it be better to tell half (or more) of surgeon Wood’s patients that they should be operated on by a less-skilled surgeon? There are trade-offs on both sides.

If you win the lottery and get treatment by the expert surgeon, you certainly prefer him to be in the room for the whole procedure. However, if you lose the lottery and are told, “Dr. Wood can’t do the really hard part of your surgery because he has to supervise the resident suturing up another patient’s wound per hospital policy,” you’d be pretty angry. And, complications from the less-skilled surgeon’s best efforts would be blamed on the surgeon or the procedure, ignoring the fact that those complications could likely have been avoided if Dr. Wood had not been supervising wound closure down the hall.

These things are complicated. My own work is not focused on improving the quality of the very best care, but rather on improving the quality of the average care — what can we do to give everyone the benefits of what we know about how to achieve the best outcomes. In that work, we often come up with situations where we recommend that one patient trade access to a world-leading expert to guide them in something routine in order for that world-leading expert to guide another patient in something critical. There is something, very small, lost to the patient in the routine encounter. In surgery, it is possible that this very small loss could lead to death, however we have to recognize that we are doing this to reduce the risk of death in other patients 10 or 100 fold.

Henry Feldman: I don’t think most people would view the primary surgeon not being there during skin closing as not being there for the operation (I guess except plastics cases where that may be the case itself), in the article they are talking major substantive parts of the operation. Not coming to the OR despite repeated requests by a trainee, and taking so long the cement has partially dried, seems like you were absent for a “substantive part” of the operation. At our hospital I can’t even be outside the curtain when the house staff put in a CVL, and have to be in direct visual contact with the patient, and site from time-out to flush (I don’t have to be there technically for suturing in and dressing). Also were these surgeons even there for the time-out?

Peter Schmidt Henry- I agree with you, and at the hospital where I did my fellowship we did not allow this at all. However, I am concerned about using the egregious case to stain a widely adopted practice. What if the resident noted a serious complication in recovery? Should the surgeon rush over? I hope so.

Also, that’s why I specified “the important part”…

Henry Feldman: Ha. I once responded many years ago to a panic call as the medical consult attending to the PACU [post-anesthesia care unit] from the PACU nurses for a patient in serious trouble. I thought it was a medical patient who was down for a procedure (it wasn’t, he was primary surgery), but ultimately they were calling because they couldn’t get the surgeons to come because “they were scrubbed” (patient did fine after I moved him to the MICU [medical ICU] – awkward!). So this is really a staffing issue on the surgical side, and the fact payment and staffing models encourage this needs to be fixed.

The discussion’s already continued (while I blogged) – let’s go to the comments now.

 

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Comments

15 Responses to “Sure to be a complex controversy: “Concurrent surgery” (Boston Globe Spotlight series)”

  1. While I was blogging the discussion continued. From Peter:
    Peter Schmidt This issue, making decisions that trade one death to save many, is a challenge that your alma mater — MIT, right? — covered recently: Why self-driving cars must be programmed to kill.

  2. And Henry added:

    The problem about the article, which was quite interesting, is that there is so little data. Mostly it seems because nobody will talk about specifics.

    It also shows (always like to tweak the competition) that Partners is not one happy family, since BWH has a completely different policy than MGH. Also, always disturbing when hospital administrators start denying that the guys on the ground (anesthesia) doesn’t actually have the facts; they were there, and their job is to record time based facts..

  3. Pete says:

    This is a hugely complex issue, where I think a key piece boils down to, should physicians make decisions prioritizing the greatest good, or should physicians stick with “doing no harm”? The legal system allows for winners and losers but we don’t want lawyers to be focusing on the greatest good – attorneys represent their clients. The question here is, at what level do we charge the system with a focus on the greatest good and at what level do we charge the system with a single-minded focus on the best outcome for each patient?

    Of course, the elephant in the room is fees….

    • Absolutely! That’s why I cited ethics and best use of resources. I’ve never taken a course in ethics but I vaguely recall hearing some classic questions where it’s always a tradeoff, as you noted in the problems a driverless car must be programmed to handle.

      Meanwhile my mind keeps going back to Hari’s advice to her patients to put in writing Only the surgeon, which gets to the transparency / honesty issue: does the patient know, and truly consent to, this practice? That’s separate from the ethical tradeoff – her advice isn’t specific to concurrent surgery.

      Note: once this is all hashed out, I don’t assume that all fully informed e-patients would say no to this. In this comment I’m talking about open disclosure of it.

  4. Pete says:

    This article represents another big issue — anecdote vs data. It outlines one case where things went terribly wrong, and, as Henry points out, the surgeon did not conform to my simple model — the surgeon be in the room for the whole time that things are going on that require the surgeon. (Gawande’s Checklist Manifesto covers workflow in the OR and how important stuff goes on that is not done by the surgeon.)

    The article brings a routine practice into the spotlight based on a case which does not represent (or should not represent) standard practice. All my scientific work focuses on populations. The big question we need to ask is, “How did this anecdote happen within the system? Is the system designed for this result, is the system unnecessarily risky that this result will happen, or did this anecdotal outcome happen because a confluence of poor decisions and circumstance combined?” I think that there were avoidable poor decisions in the case in the article, but that it doesn’t mean we should abandon the practice entirely.

  5. On Facebook, journalist Dan Munro pointed to the money issue, specifically this excerpt from the article:

    “Double-booking also fit well with the business-like approach that Dr. Harry Rubash brought to Mass. General orthopedics when he took over as department head in 1998. Rubash helped introduce an incentive system that paid doctors more if they generated more profits. Some surgeons complained about pressure to perform more operations, but others were delighted at the chance to increase their pay through extra work.”

  6. Pam Ressler says:

    Taking a look into the Orthopedic OR warrens of MGH with today’s Boston Globe article. Two huge issues jump out at me —

    1. The orthopedic surgeons are financially incentivized to do multiple surgeries at the same time (the ultimate in fee for service billing!),

    2. This is an ethical issue in which the patients were not informed and could not consent to the practice of the attending surgeon being absent for portions of their surgery.

    An integral part of patient centered care is giving the patient enough information to make an informed decision on care…this didn’t happen. After decades in healthcare I am well aware that this is a complicated issue with numerous stakeholders, however let’s put the patient in center of the conversation.

    And BTW, I believe that teaching hospitals (with all their failings) are the BEST places to receive complex care.

  7. Thanks for shining more light on this issue, Dave. I was gobsmacked when I read the original Boston Globe piece, and it was this one little line that pushed me right over the edge: the patient “had no idea he was sharing his surgeon with another patient that morning…”

    The patient had no idea? THE PATIENT HAD NO IDEA?! The patient had “no idea” that the surgeon he had met in person, discussed the procedure with, learned the risks and benefits from, and whose skill and reputation he had been impressed enough by to sign the consent form. This is surely hubris and arrogance of the first degree.

    A surgeon who flits from O.R. to O.R. (and the hospital that hugely profits from allowing such multi-tasking) may justify this practice by insisting that the Big Guy is there for the tricky bits, and the lesser-experienced Little Guys are there for the routine bits – in much the same way that my dentist schedules his patient appointments, zipping into the operatory to inject the anaesthetic for my crown prep, then running to the chair next door to work on another patient while my novocaine works and while the dental assistant sets up the rubber dam and other tasks you don’t need to be a dentist to perform.

    But the Globe report isn’t about a routine dental procedure, it’s about surgery, and it’s about full disclosure. If the practice is that ethically defensible, why not fully inform every patient of a specific hospital’s practice? We know why.

    I love the “ONLY THE SURGEON” advice here and intend to spread that suggestion widely.
    regards,
    C.

    • Of course I agree fundamentally; heck, most patients have no idea that someone else (even a supervised “student” (resident)) may be the one to cut them open and sew them up, right? If that weren’t the case, then new surgeons would have no way to get trained. (Or so I understand; anyone who knows better should correct please!)

      Having said that, I don’t get the impression anywhere in that article, nor in the discussion I pasted in, that surgeons are “flitting” cavalierly.

      Carolyn, I’d be curious – can you ask your own surgeon(s) for their thoughts on this, either for attribution or anonymously? I find it makes a big difference when I think about a specific named individual who I know in my gut (literally) is capable, thoughtful, and responsible.

  8. Laurie Barham says:

    If the practice of concurrent surgeries is so safe, it should be exposed to the sunshine. Explain to patients that their surgeries may overlap. Be explicit about which parts of the surgery may be done by someone else. Is it a matter of a resident or PA making and closing the incision?

    MGH’s consent touts a team approach. If there is a team, wouldn’t it make sense to introduce them? Don’t I have a right to know who will perform a surgery in advance of that surgery? Surely so.

    Then again, I had the experience some years ago of finding out moments before a surgery that a resident was slated to perform it — not the surgeon I had seen in a private practice. Of course, I found out quite by accident and felt incredibly betrayed that I had not been told.

    If my permission must be asked for a resident or another surgeon to do a procedure while I am conscious, how is it that no such permission is deemed necessary if I am to be rendered unconscious? Shouldn’t that raise the bar for disclosure rather than lowering it?

    MGH published a letter to its patients this morning defending the safety of concurrent surgeries. What about my right to self-determination? What about my right to informed consent? Asking patients to sign a consent that gives blanket protection to MGH to substitute any surgeon they see fit is nothing short of the first brick in an extraordinary betrayal.

  9. Vic Nicholls says:

    Interesting. Thank you for letting us know.

  10. Judith says:

    Not all of this is complex. A patient’s right to know is not complex.A hospital corralling its resources to circle the wagons against inquiry? Not complex. Punishing the whistleblower? Not complex.

    I applaud the Globe for their diligent, reasoned reporting. They invited readers to share their stories of double booking. Problem is:how do you even know?

  11. Joe Kelly says:

    Others has mentioned the ethics of informed consent
    Others have mentioned the hospital hid behind confidentiality when not addressing the issue.
    What I have not seen is the discussion of “immediately available.” MGH policy says surgeon can be in Charles River Park when surgery is being conducted. This is several blocks from surgery building. How the heck is a surgeon training anyone when he is in clinic. How long does it take this surgeon to get to the OR if something develops. Seems this needs to be explored also.

  12. Lynda Christian says:

    Anyone who may be worried about being subjected to concurrent surgery (what a name!) should find a surgeon at New England Baptist Hospital. They do not do concurrent surgery, and they have a national standing in orthopedic surgery. I just had spinal surgery there, and they were absolutely wonderful. The surgeons there are so experienced and careful. Go NEBH!

  13. This companion video summarizes much of the arguments pro and con. http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/?p1=Clash_Story_to-video#video-anchor

    • Around 5:39 it shows that about 15% of MGH’s surgeries were “overlapping” for at least part of the O.R. time
    • But in 80% of those cases, the surgeon was still present whenever there was an open incision
    • So, net-net, the surgeon was absent during an open incision (“procedure overlap”) in 3% of MGH surgeries.
    • And the question is, is that a problem or not?

    To me a major red flag is that the surgeon blowing the whistle, Dr. David Burke, was touted by MGH as just a really great guy, one of the best anywhere, until he started complaining. And then he got fired.

    I have to ask, similar to Laurie Barnham’s comment above, why on earth did they not routinely disclose this to the patient?? http://e-patients.net/archives/2015/10/sure-to-be-a-complex-controversy-concurrent-surgery-boston-globe-spotlight-series.html/comment-page-1#comment-569488 (I recommend going back and reading everything she wrote.)

    Another red flag to me is that although they say the practice is safe, the video says after the questions arose they (a) said it wasn’t a problem, but (b) added a policy about it anyway. I wonder, was it because in the absence of a policy, some took it too far? Around 6:32 in the video is this:

    “The critics complained that doctors sometimes ran two rooms simultaneously for extended periods, leaving patients waiting up to two hours under anesthesia.”

    Any patient advocate knows that time under anesthesia always carries a danger, and should be minimized. Two extra hours of anesthesia because “the surgeon stepped out for a bit”?? Seriously? If that were my relative I’d be irate, personally.

    I assume MGH’s administration knows the anesthesia risk; are they saying it’s not a problem? In what other areas are they saying “Yeah, but don’t worry about it”? I don’t know; take another look at the discussion in the original post.

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