AANS Neurosurgeon | Volume 28, Number 4, 2019


Concurrent Surgeries: Providing the Best Care for Patients

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Recent media reports have shed negative light on a common practice in surgical training: the practice of overlapping or concurrent surgeries. Grisly stories of patients apparently maimed as a result of this practice have led to public outrage. As is typically the case, much of this anger is misguided based on misinformation. Anyone intimately involved in surgical training realizes the unique demands of the sacred apprenticeship by which technical skills are passed from generation to generation. Because neurosurgery is not merely a cognitive exercise, there is necessary development of psychomotor skills that are the fruit of repetitive “hours in the cockpit” for surgical trainees. Many times the resident is the copilot, providing assistance, retraction, etc., to the surgeon. But sometimes, the resident must take the helm and practice the requisite skills he or she will need once training is finished. Certainly, the same people who are indignant at the idea of concurrent surgery would want the best trained surgeons for themselves and their loved ones in the future. To maintain the supply of properly trained surgeons for tomorrow, hands-on training in the operating room must happen today.

Examining the Evidence
For many prolific neurosurgeons, the curse of success introduces the conflict of having too many operative cases. In order to decompress the schedule, many surgeons utilize two operating rooms and overlap critical aspects of each case so that they are available for tumor removal or aneurysm clipping, while trainees perform other aspects of the case commensurate with their level of training. This creates a mutually beneficial arrangement whereby a surgeon can maintain an efficient stream of patients through his clinic and residents can hone their operative skills with an appropriate mix of direct and indirect supervision. As beautifully put by one surgeon, “A lot of the operation will be done with [the resident’s] hands. I’m doing the operation, but I’m using his hands.”

There is a great deal of evidence to suggest that the involvement of residents in surgery is very safe. Multiple reports have documented that resident participation in surgery, when adjusted for patient medical comorbidities and the type of surgery being performed, confers no additional morbidity, mortality or cost. Others have written eloquently about the potential benefits of resident involvement in surgical cases.

Informing the Patient
Perhaps the crucial lesson to be learned from the Boston Globe Spotlight article and the ensuring backlash is the importance of providing adequate information and framing expectations for patients and their loved ones. Fear and anxiety grow in the vacuum of ignorance and diminish in the light of knowledge. Alexander Langerman, MD, SM, points to the crucial ethical and practical necessity of informing patients of trainee involvement in surgical cases. Surgery is a team sport, and involving more trained professionals results in a higher level of care. Anyone who has had improvements made in their home does not expect the master carpenter to place every nail in their new cabinets or walls. Similarly, by appropriately framing conversations with patients and their families prior to surgery and identifying residents as team members, patients will have a better understanding of the crucial role of residents in their care, rather than as novices who are ‘experimenting’ on them.

Safe Care is Team-based Care
Neurosurgeons and their trainees should be bold to point out the benefits of team-based neurosurgery, resident involvement in surgical care, including in the OR, and the vital necessity of cultivating resident autonomy in the operating room. Concurrent or overlapping surgeries are not a breeding ground for chaos and mayhem. On the contrary, as beautifully put by Guan et al, “The experience gained from a modicum of operative autonomy during training—autonomy that is earned through 100s of hours of intense interactions and meted out in a carefully graduated fashion—is crucial to producing safe physicians.” Today, we are plagued by a paucity of evidence that demonstrates the benefit of these surgical practices in training programs. However, with multiple reports in recent years, this gap in evidence is being filled. Hopefully these reports will convince us, as well as our patients, that the practice of concurrent surgeries is not driven by avarice, but by the desire to provide excellent, team-based care to our patients while at the same time providing a safe and vital training environment for future surgeons.

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