AANS Neurosurgeon | Volume 26, Number 1, 2017

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For Your Consideration

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Imagine this scenario: you are seated in the waiting room of the pre-eminent academic center in your city while your family member undergoes elective surgery. When the surgeon enters the waiting room, you give a sigh of relief, eager to hear about the successful outcome. If the surgeon were to make his or her way to another family in the waiting room, what would your reaction be?

In regards to the above scenario, most of us would agree that the circumstances are of critical importance. Does it make a difference if one case is elective and the other emergent? Is it more palatable if the key portions of each operation were performed by the attending surgeon? What if the operative length/anesthetic time was increased as a result of the surgeon’s being involved in two operations?

Now imagine another scenario: You are in the office of an eminent and respected surgeon to schedule elective surgery. The surgeon discusses the scheduling options and discloses to you his or her long standing practice of performing two operations at the same time. There is discussion about the role of senior surgical trainees and oversight, including the lengthy waiting list of patients wanting to schedule surgery by this particular surgeon. Do you agree to proceed with the proposed surgery or not?

What is Concurrent Surgery?
In the March 2017 issue of AANS Neurosurgeon, the issue of concurrent surgery as it pertains to neurological surgery is examined. This variable in the delivery of health care has been present for decades in the U.S. but only recently has come under the scrutiny of the public. The Boston Globe’s Spotlight Team report “Clash in the Name of Care” in 2015 discussed in great detail the contentious issue at Massachusetts General Hospital (MGH) (1). Within the past 12 months, position statements have been issued by both the American College of Surgeons (ACS) (2) and the U.S. Center for Medicare & Medicaid Services (CMS) (5). As such, distinction is made between concurrent/simultaneous operations and overlapping operations. In the former, the critical portions of two operations are occurring all or in part at the same time. Conversely, overlapping operations are defined as those in which non-critical parts of two operations are occurring at the same time.

The advantages to concurrent and overlapping procedures are mainly increased patient access to surgeon care, efficient use of operating room resources and the delegation of responsibility as a means to increase trainees’ skill. Although the available data does not support worse patient outcomes in this setting, opponents of this practice argue that issues may arise if a trainee is inexperienced, an operation is too complex or the institution and/or surgeon is too focused on generating revenue. In addition, not all surgeons may be able to handle the multitasking required in the running of two operating rooms.

At present time, CMS requires that a surgeon, in order to bill for overlapping operations in teaching situations, “must be present for the critical or key portions of both operations.” In order to make overlapping operations safe, it is imperative that all institutions have a policy statement on overlapping or concurrent surgeries. Adverse events and their potential relationship to overlapping or concurrent surgeries should be assessed carefully. Documentation of the surgeon’s presence in (and absence from) the operating room should be part of routine practice. Within any institution, a multidisciplinary committee should provide oversight for the surgical specialties, their practices and outcomes.

In regards to the patients, obtaining informed consent should include some discussion of the delegation of responsibilities in the operating room as well as any potential for overlapping or concurrent surgeries. Open lines of communication between surgeons and their patients will reduce the potential for misunderstandings and litigation should an adverse outcome occur.

Literature Review of Concurrent Surgery
Within the past six months, several studies specific to neurosurgery have been published. Guan et al reviewed the outcomes associated with 1,018 patients who underwent elective surgery at an academic institution. Of note, all five of the senior neurosurgeons were authorized to schedule overlapping operations; no association between overlapping surgery and serious complications was noted (3). Zygourakis et al performed a retrospective review of 1,219 procedures performed by a single vascular neurosurgeon at an academic center; equivalent patient outcomes were demonstrated in the groups that underwent concurrent versus non-concurrent surgery (5).

Although overlapping or concurrent surgery may be an accepted practice in academic institutions, its existence has been a surprise to the general public. Perception is reality; it behooves every surgeon and institution to actively manage its persona and perception by the public versus it being managed for them. While further work is needed to clearly document the efficacy and safety of overlapping and concurrent surgery, the topic is a difficult one to study rigorously. A prospective, randomized study would most likely have difficulty in accruing subjects. Retrospective studies, conversely, are plagued by the acquisition of diverse data points. It is quite possible that a consensus regarding “critical portions” of operations would not be reached. Proponents of concurrent maintain that this practice is a means of building surgeon expertise as was the case for esteemed cardiac surgeons DeBakey and Cooley; in addition, this practice allows for senior level trainees to independently make decisions in the operating room, a necessary step in the education of a surgeon.

Nevertheless, of paramount importance is maintaining the sanctity of the patient-surgeon-physician relationship; the trust that is inherent in such a relationship is something to be revered and not taken lightly. To return to our hypothetical situation, when you are faced with the decision to undergo elective routine surgery, do you want your surgeon involved in concurrent or even overlapping surgery? What is your threshold?

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

2. American College of Surgeons: Statement on principles. (2016). 

3. Guan, J., Brock, A. A., Karsy, M., Couldwell, W. T., Schmidt, M. H., Kestle, J. R., … & Schmidt, R. H. (2016). Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases. Journal of Neurosurgery, 1-9.

4. U.S. Center for Medicare & Medicaid Services. CMS manual system: Pub 100-4 Medicare claims processing: Transmittal 2303. (2011).

5. Zygourakis, C. C., Lee, J., Barba, J., Lobo, E., & Lawton, M. T. (2017). Performing concurrent operations in academic vascular neurosurgery does not affect patient outcomes. Journal of Neurosurgery, 1-7.

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