AANS Neurosurgeon | Volume 26, Number 3, 2017

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Ethical Principles of Concomitant Surgery

Concomitant, or concurrent, surgery, a potentially contentious practice, has been brought national discussion particularly after the publication of “Clash in the Name of Care” in the Boston Globe (1). This editorial explored the use of concurrent surgical practices among various specialties at Massachusetts General Hospital (MGH) and related some of the worst potential outcomes that may be related to the practice. As a result, the need for meticulous reflection regarding the ethical principles that may help to guide the use of such practices is both timely and appropriate.

As a specialty, neurosurgery continues to grow, and neurosurgeons may struggle to produce quality work under the weight of an increasing patient load. All neurosurgeons are working to simultaneously provide high-quality care that fits within a timeframe that is appropriate for a specific patient’s needs.  The balance between timeliness of care, quantity of surgery completed, quality of care delivered and patient safety is precarious at best. Scheduling concurrent surgeries has been advocated by some as a potential solution to the problem of offering timely access to the most sought after surgeons. Along this line, allowing surgeons to schedule concurrent cases increases the number of patients that can be cared for during a given period and simultaneously decreases the time any patient should have to wait to receive care. Additionally, two educationally related potential positive byproducts of concurrent surgery scheduling are (1) an increase in the number of cases trainees have exposure to and (2) an opportunity to allow for appropriately monitored graduated responsibility and independence during surgery for trainees. 

Ask the Necessary Questions
Notwithstanding the potential positives outlined above, the practice of scheduling concurrent surgeries also gives rise to some potential disadvantages for both patients and surgeons. From the perspectives of both the patient and the surgeon, there are multiple questions that arise regarding the concept of concomitant surgery. These questions include at least the following:  (1) what type of informed consent process is necessary prior to engaging in the practice of concomitant surgery for patients, (2) will the level of care be adversely affected as a result of having trainees perform portions of the surgery under an indirect supervision model, (3) is there a limitation on what level of experience trainees would need to have prior to being involved in concurrent cases, (4) does this practice introduce unnecessary or unreasonable stressors for the parties involved and (5) who will be ultimately responsible for any complications that arise out of care delivered within this model?

Informed Consent From Each Patient
In discussing informed consent and concurrent surgery, Langerman supports the notion that simultaneous surgery can be of benefit to both the patient and the surgeon but also stresses that in order to respect patient autonomy, the consent process must be transparent and that more emphasis needs to be focused on educating patients about the benefits of having a team of providers deliver their care. Patients must be informed that a portion of their surgery will be performed by other providers – trainees, assistants, co-surgeons or other designees. Surgeons must “manage their trainees…knowing the abilities of the residents and fellows who will be handling the noncritical portions to ensure that patients are appropriately care for.” He gives additional support to his views by stating that “surgeons operating concurrently have a duty to plan appropriately to ensure they are available for all critical portions and can provide cross-coverage for noncritical portions if necessary (2).” This argument helps to answer questions one and three that were posed above; however, it does not resolve the questions regarding the potential for a decrease in the quality of care rendered under an indirect supervision model nor does it address the potential for increased stressors with the practice of concurrent surgery. 

More Risk for the Patient?
Many critics contend that the practice of concurrent surgery unnecessarily increases patient risk by subjecting patients to surgical procedures completed by indirectly supervised surgical trainees compared to the scenario where the attending surgeon is physically present and completing the entire surgical case. Unfortunately for these critics, there are a variety of problems with that assertion. First, there is little if any readily available evidence that an increase in risk exists if the trainee involved in this type of surgery is allowed to work independently on tasks within the surgical case that the specific trainee has already learned and mastered. If concurrent surgery scenarios only involve attending surgeons and trainees of sufficient quality and mastery, then there should not be a significant change in risk for the patient. Additionally, it is likely true that using a combination of intellects – that of attending surgeon and an upper level resident or fellow – provides superior care than that which would automatically be provided by the attending surgeon alone. The combined intellect model allows each provider to bring their own expertise to the case at hand and to solve problems with the collective intelligence of the providers instead of relying on a single provider as the sole source of knowledge.

Stick to the Schedule
The question of whether or not concurrent surgery scheduling adds unnecessary or unreasonable stress to the surgical setting may be more difficult to answer satisfactorily. On the surface, it appears that scheduling concurrent cases may certainly increase stress for the surgeon since there are more cases to manage. From an ethical standpoint, it falls to the surgeon to ensure that this does not hinder the patient’s care in any way. An accurate assessment of one’s ability and capacity in providing care to more than one patient at a time is a necessary aspect of the introspective examination each surgeon must have prior to engaging multiple patients in multiple OR settings. Assessments without consideration of patient safety fail to fulfill even the most minimal ethical obligations that physicians have toward patients – specifically, to do no harm and to render each one his due. From the patient’s perspective, the question of increased stress likely returns to ensuring a transparent and robust informed consent process. Patients need to be well informed about what will be done to them and need to be given information that is material to their ultimate choice of treatment. Uninformed involvement of the patient leads to patient dissatisfaction and degradation of understanding and/or acceptance when unavoidable problems do arise. Patients cannot be intentionally misled and must be supported if they chose to seek care in other circumstances or by other qualified providers.

The practice of scheduling concurrent surgeries is not intrinsically unethical. In fact, conceptually it may help to provide significant benefits to surgeons, patients and society. However the potential benefits for improving access to timely, high-quality surgical care and for improving training through use of graduated responsibility and independence are likely moderated by appropriate concerns for patient safety and the need to ensure that the practitioners involved in concurrent surgeries all have adequate pre-existing training to fulfill their individual roles within the demands of the surgical cases to be executed. It is the attending surgeon who bears the responsibility to ensure that appropriate true informed consent has been obtained prior to surgery; because it is that same attending surgeon who bears the ultimate responsibility to ensure that the patient’s well-being and safety remain paramount during the provision of the high-quality care that is delivered.

References
1. Abelson, J., Saltzman, J., Kowalczyk, L., & Allen, S. (2015). Clash in the name of care. Boston Globe.

2. Langerman, A. (2016). Concurrent surgery and informed consent. JAMA surgery, 151(7), 601-602. 

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