AANS Neurosurgeon | Volume 26, Number 2, 2017

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Concomitant Surgery in Education

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John Stuart Mill’s introduced us first to the concept of what may be best for an individual (in this example, a single patient) is not necessarily good for the masses (all the patients with that pathology or problem; utilitarianism). That being said, we all know the public perception. You walk into a hair salon for your first haircut; you get the person who has never, ever trained. You sit down in the chair; you are nervous. They cut your hair and sometimes it is done well: most often it is not.  The analogy of the training hairstylist to a neurosurgeon-in-training is not a fair comparison however likely the concept in the layman’s mind when visualizing a neurosurgeon-in-training. 

A neurosurgeon-in-training has completed over four years of college at the top of their class, of college. They have subsequently gone on and competed in a medical school of those who were in the top of their class in college and proved to be extraordinary individuals typically being in the top 10 percent not only in the class, but also on the United States Medical Licensing Exam (USMLE) and having developed many avocations (music, running, friends) all while perhaps authoring and publishing some papers.

These individuals then go on into a mentored environment in which senior neurosurgeons who have trained other neurosurgeons for years develop an understanding for the young doctor’s skill set and push him or her to become the best surgeon possible. We know what these neurosurgeons are capable of and know how to coerce these young surgeons along. They have graduated exposure to operative care in a seven-year residency program: often parts of the case they may be left to do without observation, they have seen perhaps 50 times before they receive autonomy to perform these parts. 

Prevention of Education 
Although education and concomitant surgery are not the same issue, they may not be entirely mutually exclusive. With overlapping surgery, I believe one of the biggest issues threatening education today is that putting rules in place that provide a surgeon only one room in which they are present continuously to operate generates a lack of flexibility and severely limits resident learning and autonomy. Although it would be appalling to the public to not have the surgeon they selected in the operating room continuously and potentially have some resident or fellow operate on them, this is something that I do not believe patients fully understand.

In most circumstances, patients go to a surgeon primarily for decision making. What is universally true – whether a surgeon practices overlapping surgery or not – is that the surgeon involved in that case takes responsibility for the case. Often times, excellent surgeons operate in multiple rooms due to patient demand and the ability of the surgeon. However, this should not be taken as a situation in which the surgeon endangers the patient. Even in the most high-profile case of Massachusetts General Hospital (MGH), the instance that generated this legal storm, the jury found that operating two rooms at once was not what endangered the patient in that environment. What is further interesting is that the trainee that may be involved aiding in that operation is being coached by the surgeon involved. Without overlapping surgery, this further injures the trainee’s progression – further exposing this person in the future to learning on patients on their own time when they are not mentored nor observed to ensure proper patient outcomes. While overlapping surgery may scare an individual – clearly independence in training and losing this has a substantial impact on future generations in that the loss of mentored autonomy will impact individual patient safety in spades when this generation is released to self-practice. 

Imagine now, the surgeon that we have trained in overlapping surgery who has had better experience than they would have not otherwise – is operating on your daughter or son in 25 years. They will simply be able to operate on your daughter or son better than those that did not have that experience. In my opinion, it is a better system for them to experience autonomy under a mentored environment in which they can be corrected and observed by an experienced surgeon that is able to stop a poor outcome before it happens.

Making Smart Decisions
How education and the medical system is affected by overlapping surgery is not anticipated by any survey. Surveys ask the patient, “Do you want the most experienced surgeon operating on you?” What they do not understand is that technical ability of surgery is actually not that difficult to master. Most surgeons do master these within their residency, in fellowship or very shortly thereafter. What is necessary is excellent decision making in the clinic and also, if an intraoperative issue is encountered, how to deal with it. This takes years to develop. That talent is what the trainee is seeking. Without time to develop their skills in the operating room with time pressure from an individual surgeon running an individual OR, this will significantly delay the resident’s learning curve.  

Anectdotally overlapping surgery may sound as the less optimal situation for patients. However, anecdotes do not affect patient care. There are multiple institutions, in fact, the best institutions in the world, that practice overlapping surgery. Their residents are the best in the world. When they leave, they are excellent surgeons. This practice is important for everyone involved, and there are far more factors to consider than an individual surgeon being in an individual room for an individual case and how that will impact the surgical outcome. All these things need to be considered with overlapping education. I believe the public should understand when we tell them that in their circumstance, overlapping surgery is in their best interest in terms of education and as well as in individual patient outcomes.

Recall, as academicians, education is our fight! We must set the path for the care of our country through quality and safe education while maintaining individual patient safety at its highest standard. The way to accomplish this is through proper education of the next generation: this is our legacy. Any public movement threatening mentored autonomy will hinder this process. Yes, education is our fight, and we must fight on. 

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