This document discusses concurrent surgery from the perspective of a surgeon. It begins by outlining surgeons' typical reactions to concurrent surgery: fear, introspection, and resolution. It then defines concurrent and overlapping surgery, and reviews guidelines, prevalence, arguments for and against the practices. Key issues are patient consent, safety, training, and efficiency. Ultimately, the author argues that patient safety should be the top priority, and that informed consent and maintaining patient trust are paramount. Concurrent surgery may be appropriate if it does not compromise these crucial considerations.

1. Concurrent Surgery
A Surgeon’s Perspective
Griff Harsh MD, MA, MBA, FACS
Professor of Neurosurgery
Associate Dean, Postgraduate Education
School of Medicine, Stanford University
Petrie-Flom Center
Harvard Law School
October 27, 2016

2. Surgeons’ Reactions
I: Fear
II: Introspection
III: Resolution
Surgery

3. CONCURRENT
SURGERY
CLASH IN THE NAME OF CARE OCT 25, 2015
It was a battle pitting a star surgeon against a great hospital, MGH.
At Issue: Is it right or safe for surgeons to run two operations at once?
Is it right that their patients may have no idea?
The conflict has been waged for years. And it isn’t over yet.

4. The index case
“At 7:42 a.m., Dr. Kirkham Wood, chief of MGH’s orthopedic spine service
began a complex thoracic spinal fusion on a 70-year-old woman.
18 minutes later, he started multiple cervical corpectomies on Tony Meng.
The two cases overlapped for 7 hours, but Wood wrote in Meng’s op note
that he was “present for the entire case.”
Tony Meng awoke paralyzed.
Neurosurgeons later that night found his
spinal cord herniated through a tear in the dura.
Meng’s attorneys say he had no idea he was sharing Wood with another
patient that day and that double-booking will play a prominent role in
their malpractice lawsuit against Wood.”

5. Spotlight report precipitated immense interest
Public blogs “Reprehensible deception motivated by greed”
H Admin “Our surgeons almost never perform CS”
Physicians Highly variable
Supportive “Acceptable and essential”
Critical “Everyone knows, except the patient”
Lay Press “CS is widespread and concealed from patients”
SPOTLIGHT: TTell us your double booking story
Surgeons We, too, are in the Spotlight!

6. Overlapping surgeries to face US Senate inquiry
Senate Finance Committee, in a Feb 2016 letter to 20 top AMCs ,
“Patients are not being informed about Concurrent Surgery and thus
might be unable to give informed consent”
The Committee demanded:
1. Policies regarding concurrent surgery
2. Policies regarding disclosure of CS to patients
3. Policies, penalties to ensure S compliance
4. Data for each calendar year 2011-2015:
Number of concurrent surgeries
Number of surgeons performing CS
Number of surgeries with any overlap
Duration of overlap of any portion
Maximum duration of overlap
Number of violations of hospital policy

7. Key Issues regarding Concurrent Surgery
1) Definitions Concurrent Surgery vs Overlapping Surgery
2) Guidelines ACS Statement
3) Prevalence Factors
4) Arguments Pro Efficiency Training Safety
5) Arguments Con Safety Training Efficiency
6) A Balanced View Caveats
7) Consent Trust

8. SFC/CMS CS occurs when an attending surgeon is conducting procedures on two or more
different patients in different operating rooms at the same time;
an attending may bill only if present during all critical portions of a case.
ACS CS occurs when critical components of procedures for which the primary surgeon
is responsible are occurring all or in part at the same time; CS is not appropriate.
What is Concurrent Surgery ?

9. ACS: Surgeries may overlap/ be sequenced (a second case may be started) ONLY IF
the critical elements of a first operation have been completed.
If there is no reasonable expectation that the primary attending surgeon
will need to return, a qualified practitioner may take over the first case, EXCEPT
when the attending surgeon is performing critical portions of a second case;
then, a second attending surgeon must be assigned responsibility for the first
case.
N.B. The primary attending should not move back and forth between the cases.
This occurs routinely, with a senior resident in one room and a fellow in the other.
What is Overlapping Surgery ?

10. Additional Definitions
“Critical portions”
those for which essential technical expertise and surgical
judgment are required to achieve an optimal patient outcome
Who decides? - the Attending On what basis? – minimal data
“Immediately available”
Reachable by page or electronically and able to return immediately
Time 5, 10, 15 min (specified by local institution)
Location nearby OR / clinic / office +/- video monitor
“Qualified practitioner” licensed professional with sufficient training
Attending, fellow, resident, PA; (judged by attending, hospital)
“Backup attending” designated qualified attending surgeon
Fellow / Clinical Instructor v Rank Faculty?
Subspecialty expertise?
Informal availability v call schedule?

11. Prevalence and Duration of Overlapping Surgery
MGH 15 % (Ortho 25%) with scheduled overlap
3 % open incisions simultaneously = 1000 cases / year
Wisconsin 1% an average of 15 min
Stanford numerous examples of parallel schedules
Time/Room OR 18 (Right) OR 19 (Left)
7-10 am Patient A1 Patient B1
11-2 pm Patient A1 Patient B1
3-6 pm Patient A1 Patient B1
P (OS) <>
AMC v non-AMC Hospital 4* v 1* Specialty
Surgeon P, Busy Procedure %C Situation R v Em

12. For Overlapping Cases and an Attending’s Absence
Training requires it.
A resident cannot achieve independence with an attending present.
Safety is not compromised.
Attending can judge a resident’s progression to independent competence.
Efficiency demands it.
Absence from OR is essential to efficient use of a skilled surgeon’s time.

13. Benefit of Overlapping Surgery
Surgery, esp start and finish, is often routine, simple, time consuming
patient intro, anesthesia induction, positioning, sterile prep, set up,
localization, initial exposure; hemostasis, closure, awakening
Often, the primary surgeon’s presence is simply not needed
Absence from OR is essential to efficient use of a skilled surgeon’s time.
promoted by hospital’s desire to keep a productive S busy
Altruistic exercise one’s skill to benefit more patients
Mercenary salary (hospital pressure), promotion, prominence, ego
N.B. both presume the surgeon is uniquely skilled – very rare

14. Against Overlapping Cases and an Attending’s Absence
Efficiency may not suffer.
OR efficiency, improved by the A’s presence, supersedes the A’s efficiency.
Training does not require it.
An A’s presence does not preclude a R’s progression to independence.
Safety may be affected.
Safety must be proven by more than subjective judgment.

15. Risks of Overlapping Surgery
Although surgeons try to schedule cases so as to avoid concurrence,
Attending Absence during CPs can still occur
Patients are scheduled far in advance and asynchronously
Cases proceed unpredictably (anesthesia, unique anatomy)
Resident assignments and abilities vary
Critical events may occur unexpectedly (“routine opening”)
Dilemma : when Attending is unavailable
Assistants stand idly  prolonging the case  increasing CX
DVT/PE, pneumonia, wound infection OR
Assistants proceed to CPs for which they are unqualified.
Neither is safe

16. Risks of Overlapping Surgery Evidence is scant
MGH reviewed of 25 concurrent surgeries that had complications and
found none attributable to double booking
The Doctors Company found no mention of concurrent surgery as a factor
in 7,330 malpractice cases
Zhang et al. J of Bone and Joint Surgery, 2016
No difference in outcomes of 3,640 overlapping and non-overlapping
operations wrt procedure time, time in the OR, complication rate.
Yount et al. AM American Association of Thoracic Surgery, 2015
Attendings’ performing simultaneous cardiac operations in academic MCs
does not increase case duration or adversely affect patient outcomes.
Need EMR-enabled correlations of extent of attending
involvement in hypothesized CPs with patient outcome

17. My View Hierarchy : Safety > Training > Efficiency
Safety is the paramount consideration.
Learning curve for skilled procedures 
any part is likely safer with the A present
Caveat: added benefit may be minimal
Training is likely enhanced by an A’s presence
Caveat: R competence may abrogate the need for more training;
optimal outcome may be achieved by a less experienced resident
operating alone if autonomy is granted only as earned by skill.
This requires accurate judgment of task complexity & R aptitude.
Most data suggest that attendings are getting this right.
Efficiency is a tertiary consideration (hospital’s may >; A’s will <)
Having Rs assist in non-op care more than compensates
The Attending should be present when outcome is at stake
or training opportunities exist.

18. Overarching Consideration
Patients expect the attending to be involved throughout the case.
JAMA Surgery : only 18% of patients would consent to a resident
“acting as operating surgeon with or without staff observation.”
That patients don’t know implies patient consent is not truly informed.
The participants and their roles are not adequately explained?
The potential absence of the primary surgeon is not explicit?
Consent = Salient issue of medical and lay response to Spotlight series
As long as patients feel inadequately informed,
Malpractice suits will multiply
Regulation will proliferate
Patient-physician trust will be eroded.

19. Trust is the foundation of the therapeutic relationship.
it is the glue of the sacred bond between patient and physician;
all other considerations derive from it.
This trust is mutual:
The belief by the patient that if he/she puts his/her life in our hands, we will do
our best to ensure an optimal outcome; and
the assumption that if we do give our best, we will not be blamed for failure.
This mutual trust emboldens both patient and physician.
It fosters in patients the courage to allow us to undertake needed surgery; and
it encourages us to risk failure and to face the criticism from ourselves and others
that failure may bring.
Warranting a patient’s trust is essential to a physician;
that we act in trustworthy fashion both
gives our efforts meaning (we serve others in a way that warrants trust and
gratitude) and
allows tolerance for less than optimal outcomes (we can reconcile with failure
only if it has occurred despite our best effort).

20. Informed Consent = tangible manifestation of this trust
I am your surgeon; I will do my very best
to achieve an optimal outcome for you.
I will be highly engaged throughout your surgery;
“I will be scrubbed and actively involved in the critical parts of your surgery,
but for non-critical parts of your operation which my resident will
perform,
I may be operating in another room or in my office, but I (or my faculty partner)
will be able to return immediately to your room if needed.”
I also have an obligation to train future surgeons
for the benefit of future patients – just as I was trained for your benefit.
And I try to be efficient with hospital and societal resources and my time
so that as many patients as possible may have the same quality of care
that you hope to receive.

21. So, depending on the part of the case and
the experience and ability of the other surgeon(s) working with me,
My engagement may take different forms:
I am scrubbed and perform the surgery
I am scrubbed and assist another surgeon
I am in the room, not scrubbed, but supervise the operation
I am not in the room but direct the other surgeon by planning
of your case and my previous training of the other surgeon.
.
Regardless, I vow to you that my choice in this regard will be guided
by my desire to achieve the best possible outcome for you and
that this will not be compromised by other considerations.

22. Surgeons’ Progression
I: Fear
to
Action
II: Introspection
to
Analysis
III: Resolution
to
Principled Practice
Surgery
Informed Consent
Mutual Trust