Gray Matters: Bringing Polemic Issues With Inchoate Guidelines Into Sharper Focus
Corinna C. Zygourakis, MD
Recent debates on concurrent/overlapping surgery have focused primarily on the patient’s or the attending surgeon’s perspective. Since the patient always comes first, it is appropriate that we begin with demonstrating that overlapping surgery can be performed safely and efficiently for our patients. Three analyses (1-3) from our own institution show longer procedure times but equivalent patient outcomes in overlapping versus non-overlapping neurosurgical cases. We believe this is essential information for us to share with patients when we explicitly inform and consent them for their procedures.
From the attending’s perspective, overlapping surgery allows them to perform more cases during business hours, rapidly increasing their surgical expertise. It allows them to deal with neurosurgical emergencies and to care for patients in a more timely fashion, maximizing their positive impact on the patient population. But how does concurrent/overlapping surgery affect residents?
Our main goal as residents is to learn as much as possible so that we can become competent, independent surgeons. We learn in several ways: through observation (e.g., “I watch Attending X operate”), observed operation (“Attending X watches me operate”) and unobserved operation (“I operate while Attending X is in another room”). In the first method, we observe and assist the instructor, who safely and quickly completes the operation. While this may often be the safest for the patient, it is not maximally effective for the resident, as technical fields like ours require practice (rather than mere knowledge or observation) in order to achieve mastery. How can we become independent surgeons upon graduation if we only observe during our surgical training?
With the second method (observed operation), the instructor observes and coaches the resident, which may slow the surgery but still mostly ensures safety and educational value. Finally, with the third method (unobserved operation), we operate independently. We covet this learning opportunity that is only made possible through concurrent/overlapping surgery. It gives us independence and is critical in training us to develop manual dexterity, think on our feet and confront pathology firsthand. It forces residents to take ownership of surgical planning, to make judgments about when we need support/guidance and allows us to better understand our limitations. The opportunity for more independent operating is especially important for senior-level residents, as this serves as a bridge from the early days of residency when we are just watching cases, to what is expected of us as an attending, when we will soon be solely responsible for the entire surgery.
These three approaches to learning can therefore be viewed as a progression, and as we gain more experience, our day-to-day shifts increasingly towards unobserved observations to better simulate the responsibilities of an attending.
As surgical trainees, we are important contributors to the safe execution of concurrent/overlapping surgery, as well as its beneficiaries. Another important point is that young surgeons must master surgery in one room before we move on to operating in two rooms. A big threat to concurrent surgery is not doing it well- we must insist upon self-reviews and internal regulations to ensure that only the most capable, experienced surgeons are performing concurrent surgery with optimal outcomes for their patients.
1. 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.
2. Zygourakis, C. C., Keefe, M., Lee, J., Barba J., McDermott, M. W., Mummaneni, P., & Lawton M. T. (2017). Comparison of patient outcomes in 3,725 overlapping versus 3,633 non-overlapping neurosurgical procedures using a single institution’s clinical and administrative database. In press, Neurosurgery.
3. Zygourakis, C. C., Sizdahkhani, S., Keefe, M., Lee, J., Chou, D., Mummaneni, P., & Ames, C. P. Comparison of Patient Outcomes and Cost of Overlapping vs Non-overlapping Spine Surgery. (2017). World Neurosurgery.
Vikram C. Prabhu, MD, FAANS
Each year, hundreds of thousands of patients receive the highest quality care at medical centers around the U.S. It is by far the best medical system in the world and arguably the most efficient. While there are excellent medical facilities in other parts of the world, they merely complement the American system and have either contributed to its current form or imbibed some of its practices. In other words, this is as good as it gets. Sure, there are criticisms and the system does have its flaws: it is expensive, litigation averse and prone to reliance on excessive tests that are sometimes unnecessary. And sure, physicians have a pivotal role in the system, but the etiology of those problems is complex and multifactorial and driven in large part by the legal environment, medical and pharmaceutical industry pricing, insurance covenants and patient expectations.
A more recent criticism that beset the medical system was the assertion of an adverse outcome of a surgical procedure due to the fact that it was a concurrent surgery; in other words, the primary surgeon may have had two patients under anesthesia at the same time and participated in two surgeries simultaneously (1). Subsequent allegations of patient harm, surgeon misconduct and inappropriate billing triggered an investigation by the Senate Finance Committee that has jurisdiction over the Medicare and Medicaid programs (2). This committee looked at the matter closely, noted somewhat sparse literature on the topic and reached out to physicians and administrators at major academic medical centers across the country; and other organizations got involved as well, including the Center for Medicare & Medicaid Services (CMS) and the American College of Surgeons (ACS) (2,3).
In fact, the ACS, the AANS and major neurosurgical national societies, including the Congress of Neurological Surgeons (CNS), the Society of Neurological Surgeons (SNS) and the American Board of Neurological Surgeons (ABNS), with jurisdiction over most practicing surgeons in the U.S., recognized the problem and have taken the lead in framing the issue and providing clarity to their members, and other affiliated organizations, as to what is acceptable (3,4). They most categorically proscribe against the practice of concurrent surgery, defined as “when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time.” However, they also clarified the verbiage; “overlapping surgeries” is the nom de plume and acceptable under certain select circumstances; “In instances when the “critical or key” elements of one operation have been finished and “there is no reasonable expectation” that the primary attending surgeon will need to return to the operation, a surgeon can delegate less critical or non-critical parts of the operation to another surgeon or qualified practitioner while he or she begins an operation in another room. When the critical components of the first operation have been completed and the surgeon is performing critical components of an operation in another room, the surgeon must assign responsibility of the first operating room to another attending surgeon”.
These overlapping surgeries are considered suitable as long as they do not negatively impact the seamless and timely flow of either operation. There are caveats; foremost is the obligation of the surgeon to ensure that the patient is informed. Other key provisions emphasized are the surgeon’s responsibility to patient safety, to precisely define what constitutes critical parts of the operation, to ensure appropriate personnel are available to care for the patient and to be physically present when required or immediately available via pager or other electronic means to return to the operating room when required (3,4). The value of being able to reach out to a colleague as a backup surgeon, and making sure a patient or family knows that, is immeasurable and also strongly recommended (3,4).
Patient and Surgeon Relationship
There is no doubt about the emphasis that our neurosurgical organizations place on the sanctity of the relationship between a surgeon and his or her patient (3,4). That is at the core of our mission and it supersedes everything (4). But, there is a tacit recognition of the pivotal balance of clinical care and education and residency training; and an understanding of the benefits of the current system, with the need to simply correct the few anomalies or outliers. A recognition that the process, in most academic centers where it may occur, is not haphazard but rather carefully orchestrated to ensure maximal safety and efficacy, is a valuable part of the residency training process and provides a tremendous advantage to patients who are cared for in a timely manner and can avail of the expertise of the attending physician. Experienced and skilled attending surgeons can, in fact, accomplish this with ease and ensure both patients are well. In addition, the residents and fellows benefit from the experience of independent and appropriately supervised surgery and gain the confidence necessary to perform these tasks on their own in the near future.
The Result of Concurrent Surgery
Remember, this is the most prized aspect of residency and fellowship training and what prospective candidates seek out the most when they evaluate a training program; the ability to gain confidence and knowledge through some degree of independent surgical practice. It does create a competent new surgeon who can then safely practice following graduation from the training program. And, attending physicians do not assign these tasks lightly; the residents and fellows demonstrate the requisite knowledge and expertise to be entrusted with the tasks and the Accreditation Council for Graduate Medical Education (ACGME) allows a meaningful and objective assessment of their progress through a set of developmental milestones that are rather comprehensive.
In fact, the ACGME recognizes the crucial importance of this teaching model and devoted considerable time and intellectual energy with input from multiple disciplines to formulate a document that is enshrined into residency training (5). There is great detail and granularity that evaluates every aspect of the residents progress, “The Milestones describe the learning trajectory within a sub-competency that takes the resident or fellow from a beginner in the specialty or subspecialty, to a highly proficient resident or fellow or early practitioner.”(5) It is a well thought through strategy to serve the public interest in the best possible way. This is a classic paradigm of apprenticeship and graded responsibility that has flourished all over the world for centuries and that has produced the best craftsmen and surgeons throughout the ages.
Neurosurgery, and other surgical specialties, have a rich tradition of attracting the best and the brightest and are fortunate to have residents and fellows with a deep sense of commitment with exactingly high-standards. These superb young men and women are the fabric of the academic system; without them, it would fray and dwindle. In fact, there is little doubt that the master surgeons of today were the eager and bold apprentices of yesterday. The public that reaps the benefits of their skill does so because someone entrusted the appropriate task to them at the right juncture allowing them to hone their skills. This is perhaps the critical element; the judgement of the attending physician is paramount in determining who is entrusted with what aspect of a patient’s care. This careful appropriation of responsibility occurs on a daily and hourly basis in every medical setting, whether surgical or non-surgical, and is the bedrock of the best crucible of medical training the world has ever seen. It is on purpose not Socratic but rather experiential and it is precisely why trainees flock to the U.S. from all over the world to learn and be better surgeons. It is also a competency-based model that follows a tradition that goes back almost a century in our country and that has been embraced by the ACGME (5). Studies from reputable academic centers performing large volumes of surgical cases, and graduating some of the best physicians in the world, where overlapping surgeries occur, show no adverse effects from the practice (6).
There is No “I” in Team
There are other intangible benefits; attending physicians are human and need help. They cannot physically perform every aspect of a surgical procedure or after-care and have to entrust some of this to other individuals at some point, especially with complex and difficult or lengthy surgeries. Patients and lawmakers have to recognize that although the attending physician is primarily responsible for the care of the patient, this is a team effort. Our finite numbers and busy surgical schedule, not to mention other administrative and academic responsibilities, places an enormous burden on us and there is a fine balance between our responsibility as physicians and teachers. The clamor to only schedule one surgery at a time is equally rivaled by the clamor to get surgery done for everyone in a timely manner.
Fatigue and burnout are rampant in the medical profession and significantly among surgeons (7). We have made progress in resident duty-hours but I feel we have not addressed the problem of stress and fatigue among practicing physicians. The enormous pressures of increasing documentation, the constant barrage of reminders to complete training modules that are mind-numbing and immensely time consuming, the pressure to meet performance and productivity targets or provide quality metrics, the fear of litigation and the erosion of our academic pillars of thoughtful research and scholarly work have created an environment that places a great burden on physicians.
There is nothing more precious or rewarding to a surgeon than to be able to quietly focus his or her attention on the task at hand without the stress of having to be responsible for another patient at the same time or having to answer pages or calls that have no respect for the moment. Most medical centers, including ours, have rules that counsel against concurrent surgery. The ACS and AANS guidelines are clear on the matter, and governing bodies such as CMS and accreditation agencies such as The Joint Commission, require hospitals to adhere to nationally prescribed standards (2). Within this framework, in carefully selected circumstances, with appropriate judgement, with requisite training and expertise available, overlapping surgery is feasible and may benefit a patient tremendously without portending a negative outcome (7). The attending physician does not abrogate any aspect of their responsibility to the patient; he or she is still the leader of that team and has to ensure everything goes smoothly and according to plan.
This is a methodology employed by all professions; lawyers, politicians, financiers, pilots, sailors, and even editors and those in the press, all have a system of careful delegation of responsibility while maintaining final authority and taking full responsibility. Even anesthesiologists are so pressed for time and manpower that they rely on residents and nurse anesthetists to help them with their cases; one staff anesthesiologist may be responsible for more than one patient under anesthesia at the same time.
Top of Their Class
It is imperative not to take a myopic view of how surgery is conducted in busy academic centers. These superb institutions are the pillars of our medical establishment and have trained some of the best physicians and surgeons in the world. Sure, for a busy surgeon, concurrent or overlapping surgery may translate into more productivity as measured by relative value units that may impact reimbursement. But these complex dynamics are not easy to conflate. There is good reason those very surgeons are in such high demand; they are simply the best at what they do and are part of a very finite group of highly skilled practitioners. They also have the ability to positively impact many lives. They are also among the best educators and have taught scores of accomplished residents who have gone on to illustrious careers in both academics and private practice.
A common scenario at an academic hospital is an attending physician is performing a scheduled surgery, say for an aneurysm or brain tumor or complex spine case, that requires their presence and focused attention, and an emergency arrives that may be life-threatening and needs attention right away, such as an epidural or subdural hematoma or a shunt malfunction. A second attending neurosurgeon or colleague may not be available to staff that case and a senior level resident is easily competent enough to take the latter patient to surgery and perform an operation with minimal supervision that will save the patient’s life. Even with elective cases, there are so many instances in which an experienced and knowledgeable resident to assist you, or getting a second room started, has had a positive impact on the outcome.
Remember, the ACGME mandates that we certify which procedures the residents are capable of performing under supervision and those they can perform independently, and the residents expect us to teach them to do exactly that. It is reasonable to assume the ACGME recognizes that in order to produce the best physicians and surgeons, they have to mature into independent practitioners while under the umbrella of their training programs. This is their core mission: to accredit organizations that provide the best physicians to care for the public at large. It is the safest way to ensure that licensed and board certified physicians have the necessary skills to fill the shoes of their mentors. As with similar situations in which a public outcry over a sentinel event risks destabilizing an entire system, sage and experienced leaders have gently reset the bar to incorporate positive change and avoid an overreaction. The resident duty hour debate was a similar learning moment and through a careful and assiduous process, the ACGME has instituted a system that is fair to residents and does not compromise patient safety.
There are genuine concerns about the ethics of two simultaneous operations occurring without a patient’s consent prior to surgery; or in emergent situations, the importance of informing a patient and their family immediately following surgery (2). There is no doubt about that; we should be honest and transparent with our patients. I also routinely introduce my patients to our residents and acknowledge the fine and critical contributions made by them. Patients appreciate this; they realize these are not novices but rather licensed, mature, motivated, responsible and conscientious physicians and that this is truly a team effort. They develop relationships with our residents and recognize the critical role they play in their care and routinely relay that appreciation back to me or in the form of written accolades. Overall, the practice of overlapping surgery, done occasionally, very selectively and with appropriate personnel, does allow more efficient throughput. At times it may be essential, and it probably is not as perilous as made out in the lay press. In the exceptional or truly emergent circumstance, concurrent operations may occur, but once again, with careful appropriation of personnel and with the sole intent to provide the patient with the best care in a timely manner.
We have to have faith in our profession and the system we work in; it is the best of its kind in the world. Some of the disquieting events we are observing is because we are placing too much stress on it and expecting too much from physicians. We need to slow down and go back to the basics. We all have a stake in this. The American Medical Association (AMA) Code of Medical Ethics, adopted in 1847, and recently updated in 2016, nicely articulates the standards and values that physicians must abide by (8). As physicians, our responsibility is great, and the public places their trust in us like in no other profession. Our Hippocratic oath and the ethics of our profession should guide our every action. The inconsonant pressures placed on physicians stretch the boundaries of our training and the way we conduct ourselves. We have to moderate these discussions that govern our lives and those of our patients. We have the unique opportunity to make patients’ lives better and should be honored and humbled by that privilege.
We have the opportunity to mold the next generation of physicians and surgeons and it is incumbent on us to nurture and teach them to be exceptional as they venture forth into the world. Each one of us should examine our practices, our responsibilities to our patients, and our commitment to the education of our residents and fellows. Hospitals should have clear-cut regulations of what is acceptable practice and strict rules regarding compliance and patient disclosure; it is likely that CMS and other governing bodies will expect these standards and link them to reimbursement in the near future (2). We must use introspection, transparency and adverse events in an affirmative manner to effect positive change. We must remember the profound vulnerability our patients encounter when they leave the comfort of their homes to enter an alien and forbidding environment. We must guard this sphere and ensure the best is done by them. Sentinel events in medicine can sometimes become a squall that sweeps away decades of good work. We have to gently push back against various pressures laid upon us and rely on our own best judgement that is steeped in tradition and ethical conduct (3,4). We have the requisite training for that and our residents and fellows will follow our example and fill our shoes admirably.
4. Intraoperative responsibility of the primary neurosurgeon. Policy Statement of American Association of Neurological Surgeons, American Board of Neurological Surgery, Congress of Neurological Surgeons, Society of Neurological Surgeons. July 20, 2016.
6. 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.
THE EXPERTS WEIGH IN
William T. Couldwell, MD, PhD, FAANS
From a department chair and neurosurgical leadership position, I believe the issues have been framed well by Drs. Prabhu and Zygourakis. Concurrent surgery, defined by simultaneous performance of the key portions of more than one case under the supervision of one attending surgeon, is not allowed in most academic hospitals nor is it condoned by any national surgical organization. As stated by Dr. Prabhu, overlapping surgery, defined as completion of the “critical or key” elements of one operation, prior to entering the second case, with “no reasonable expectation” that the primary attending surgeon will need to return to the operation, is the controversial practice under current public scrutiny. In many subspecialty academic teaching centers, it is performed with the intention of enhancing the efficiency of delivery of patient care, by extending the productivity, and availability, of the experienced attending specialist surgeon while working within an inherently inefficient teaching hospital system, associated with long operating room turnover times. As noted by Dr. Zygourakis, it provides some progressive independence of trainee experience, necessary for transition to practice. Recent literature from neurosurgery and other specialties now emerging provides some assurance of safety as overlapping surgery has been conducted in these particular academic institutions (1-3).
How might some of the issues of concern to the public be addressed in a meaningful way by hospitals: Hospital Operating Room (OR) Committee authorization of specific surgeons who are able to perform overlapping surgery. Such surgeons should be sufficiently experienced, have a busy practice in their area of expertise and have demonstrated the ability to run an operating room environment efficiently as defined by their national benchmark case durations. They should have a busy surgical practice to justify an overlapping surgical practice, so as to not induce delays in patient access and care. Authorization could be linked to academic rank or to the demonstration to the local OR committee that this would be in the best interest of patients seeking access. Here are some critical points to consider with this type of surgery:
1. Definition of the key and critical portions of the overlapping surgical procedures to assess the value of such an approach.
2. Designation of a qualified secondary attending surgeon who will be immediately available to assist with the first procedure if needed.
3. Credentialing of residents concurrent with residency milestones.
4. The milestones created by the Society of Neurological Surgeons (SNS) have been implemented to codify resident progress. These milestones provide a competency basis to justify graded independence in the performance of surgical tasks. Our residents and fellows are licensed physicians in most states (residents past their first year), and credentialing concurrent with the milestones would allow them to perform simple opening and closing procedures.
5. Full disclosure to patient as to the nature and purpose of overlapping surgery.
6. The consent form for surgery should be modified to clarify that either the primary attending surgeon, or a designated and qualified backup attending surgeon, will be present throughout the surgery or immediately available to assist. Both attending names could be present on the signed consent form.
7. Careful OR Committee monitoring of the overlapping policy and its implementation, with regular feedback on the process to the attending surgeon and the Medical Board of the hospital.
8. Any lapse or violation of policy would be reviewed with subsequent action plans for reparation. Specific review of morbidities in monthly conference could be performed in the context of overlapping surgery, and flagged if deemed related.
9. Institution of formal policies for Medical Board approval pertaining to the items above.
1. Guan, J., Brock, A. A., Karsy, M., Couldwell, W. T., Schmidt, M. H., Kestle, J. R., … & Schmidt, R. (2016). Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases. Journal of Neurosurgery, 1-9.
- 2. Hyder, J. A., Hanson, K. T., Storlie, C. B., Glasgow, A., Madde, N. R., Brown, M. J., … & Habermann, E. B. (2017). Safety of Overlapping Surgery at a High-volume Referral Center. Annals of Surgery.
- 3. Zhang, A. L., Sing, D. C., Dang, D. Y., Ma, C. B., Black, D., Vail, T. P., & Feeley, B. T. (2016). Overlapping Surgery in the Ambulatory Orthopaedic Setting. J Bone Joint Surg Am, 98(22), 1859-1867.
2017 AANS/CNS Section on Pediatric Neurological Surgery
Nov. 28-Dec. 1, 2017; Houston
2nd Homburg ICP and Hydrocephalus Workshop
Nov. 28-30, 2017; Germany
22nd Instructional Course and 45th Annual Meeting of the Cervical Spine Research Society
Nov. 29, 2017 - Dec. 2, 2017; Hollywood, Fla.
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