Overlapping Surgery and the Golden Rule
When considering patients for surgery, most if not all neurosurgeons ask themselves, at some point, what they would want done for themselves or for their loved ones. Not a few patients and families ask the same question and for good reason. While the question doesn’t guarantee an honest answer, few of us would not give one.
Planning more than one elective operation to take place at the same time has many different names, as neatly summarized in this article, “The Many Definitions of Concomitant Surgery.” For brevity’s sake, I will cover only the topic of “overlapping surgery” in this article. Neurosurgeons schedule overlapping operations so that they can finish their operative day before 11 p.m., get at least some sleep, have time for non-clinical work (be it research, administrative responsibilities, etc.) and still maintain a “life” (crazy, right?). This is a worthy goal. There may be benefits to resident and fellow education that result, or not, as discussed in this issue’s Patient Safety article entitled “Concurrent Surgeries: Providing the Best Care to Patients,” but these are “fringe benefits” to performing overlapping surgery.
The “Golden Rule” is ubiquitous around the world, with slightly differing emphases that reflect the language and culture in which it is expressed. It always reflects the principle of “do unto others as you would have others do unto you.” Planning overlapping surgery is as good an arena to put this rule to the test as any. Would you be willing to undergo an operation knowing that your surgeon would not be giving your whole procedure his or her undivided attention?
Michael T. Lawton, MD, FAANS, makes a convincing case for the benefits of overlapping surgery in his article entitled, “Point: In Defense of Overlapping Surgery at Academic Medical Centers.” If residents or fellows will be doing the opening and closing of a complex surgical case anyway, why not avail yourself of the services of an experienced expert? Does it really matter so much if, for some period of time, that attending neurosurgeon’s name is featured on two rooms of the OR board, as long as he or she is there for the key parts of the case?
There, indeed, is the rub. What are the “key parts?” What about things going awry during the “routine” part of surgery, such as a wrong spine level exposed or a misplaced craniotomy? If the attending chose to exclude himself from the room so as to give the resident “a long leash,” knowing that he or she could “fix the problem” should one arise, that is one thing. But, if he or she could not be in the room because a simultaneous case became unexpectedly complicated, how can that be justified? Review “Counterpoint: Concurrent? Overlapping? Simultaneous Surgery? A Question of Informed Consent” for a look at the other side of the argument.
Of course, there are now multiple studies that demonstrate that there is no increased surgical risks related to properly planned overlapping surgery. A patient may in fact be better off in expert hands running two rooms than in a room where a relatively inexperienced surgeon is present the whole time. But this may be an example of the difficulty of applying statistics to individual cases. How can you know that during your surgery there will not be a problem in the other room that will leave a resident stranded, without the supervision of that revered neurosurgeon you traveled so far to see? Read the articles that address this dilemma in the current issue. I hope you will find some answers and come up with some good questions, as well.
With this issue, I conclude my tenure as the editor of AANS Neurosurgeon, a job I have enjoyed immensely. I would like to thank everyone who has contributed to the publication over the last seven years and eased the transition to an online format. In particular, I would like to acknowledge the enormous support of AANS staff including Manda Seaver, John Iwanski, Deborah Cassell, Lisa Schroeder, Becky Artz and Terra Miller. Thanks a ton, and here’s to my friend, Deborah L. Benzil, MD, FAANS, who will make AANS Neurosurgeon even better in the years to come!
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