Counterpoint: Concurrent? Overlapping? Simultaneous Surgery? A Question of Informed Consent
Thank you for giving me the opportunity to give a counterpoint on the question of concurrent surgery. I must say, I found this a difficult task. Opinions are strong, and history is well-established at many centers. Nevertheless, when I researched the topic, I was surprised by the amount of confusing information present, including literature put out by hospitals and by surgeons. Therefore, I thought it would be important for neurosurgery to discuss this issue or to at least frame the question us for our review.
My goals is to define and clarify the question to allow intelligent discussion and to suggest a course of action which I believe is best for our patients and therefore our profession. I will say from the start that I am going to take the point of view of the patients on this issue of concurrent surgery and that there are three caveats. One – that I am talking to the American Association of Neurological Surgeons (AANS) – including, I believe, the best and most brilliant in American neurosurgery, and I fully understand that sometimes exceptions must be made for exceptional people. Some of that may be in play in this debate and I accept that. Second, I am talking about elective cases, and I will spend very little time on emergent cases. Finally, in reality, I am talking about far more than concurrent surgery; I am talking about informed consent and the obligations that come with that. So with that in mind, where do we begin?
Some Adjustments Need to be Made
Some years ago, I journeyed down to a major Midwestern city to sit with my mother while my father was having a cardiac procedure. It was a terrible experience. My mom sat in a large cattle call room. It was dirty. It was noisy. It was crowded. She felt unsafe. There was no word whatsoever from the OR until what seemed to me to be a far longer period of time that was necessary for the procedure. Then, a disheveled man appeared and told my mother what a wonderful surgeon he was and left. At this point, I had to switch from my family member role to my doctor’s role to tell my mother what I thought the doctor probably meant to tell her, what I thought had probably happened based on what I could glean. Two things became apparent to me: This was no way to treat patients’ families waiting during surgery, and I was appalled how little information my mother had actually received pre-op, during the surgery or after the surgery from the doctor or staff. So what do you do?
First, change the waiting room. The University of Wisconsin surgical waiting room is bright, clean and comfortable. It has artwork that changes every month. It has widescreens, telephones and computers. There are two very excellent young staff people who keep track of all the families, who give them beepers if they are going to go to breakfast and give them reports from our OR nurses by the clock as to how the case is proceeding. When it is time for the surgeon to come down to talk to them, they escort them to a private room for that discussion.
The second is really the question of how we inform our patients and their families. I believe firmly that doctors are teachers. Indeed, that is what the Latin word “Docere” means: “teacher.” Surgeons as teachers make certain that patients understand what they are getting, and then we deliver it. That is the way surgeons participate in patient care. That is the way they understand the disease process and is really one of the most important factors in them doing well. So, I believe the question of concurrent surgery – yes or no – is really a basic question of informed consent and historically, academic neurosurgery of yesteryear had not met the standards that our patients now expect of us.
The Issue at Hand
This issue came to a head on one day, Oct. 25, 2015, when the Boston Globe published a 12,596 word essay, or spotlight, on concurrent surgery entitled, “Clash in the Name of Care”(1). In brief, a hospital disagreement played out in public highlighting the issue with resulting damage to both people and the public’s confidence in surgical care. At root was one of the doctors doing concurrent surgery (three operations in two operating rooms). One of the patients had an unexpected complication, and at the malpractice trial, the family was surprised to learn that the doctor was simultaneously booked in two separate rooms at the time that their family member suffered the complication. It is important to understand that the Boston Globe did not say whether the practice of concurrent surgery was right or wrong. It simply said that this was not what the patient and family had expected.
All of this raises the question: How would you want your mother or family member cared for? Would you want your mother treated if the surgeon was doing four cases at once or 20 major cases in one day? What if the surgeon was across the street running a clinic during your family member’s surgery?
Definitions of Informed Consent
So to really get to the root of this problem, we need to define the terms of informed consent, some of which have been blurred in the media:
- The first is the critical portion of surgery. This is the key part or the part of the surgical procedure that is unique to a specific surgery and necessary for its successful completion. At the present time, it is defined by the surgeon.
- The second is concurrent surgery. This is really the crux of the issue. This is two or more operations being done concurrently by the same surgeon when the critical point portions of the surgeries overlap.
- The next is simultaneous surgery. This is exactly the same as concurrent surgery but has been used, unfortunately, in a confusing manner. When asked, did they do concurrent surgery – the response was, “No, we do simultaneous surgery,” which causes confusion and does not shed any light.
- The final is overlapping surgeries. This is when two operations are being done where the critical portions of either case do not overlap. For example, assistants are opening in one case while closing is going on in the other, but the critical portions are tended to by the attending surgeon for each case.
Arguments in Favor of Concurrent Surgery
Now, when we look at concurrent surgery, our question today is what are the historical arguments given for concurrent surgery?
It allows surgical brilliance to be shared by more patients. I fully understand this. There are exceptional surgeons, and exposing more patients to their care may well be something that rings true, especially as I believe the membership of AANS includes many exceptional neurosurgeons. The second is productivity: the “Deming argument” that concurrent surgery increases efficiency. But the question must be asked, productivity or efficiency for whom? The final is education. That is, “This is the way I was trained,” and graded responsibilities required a period of time when I was unsupervised and making my own decisions was historically important in my education.
Let’s look at each of these individually. First, the brilliance argument. One surgeon in India does 20 cardiac bypasses per day. The explanation given by a professional lobbyist is that the surgeon is one of the world’s greatest knot tiers and to have him simply tie a knot on each case would be important. I compare this to Michelangelo’s Sistine Chapel’s portrayal of God touching Adam fingertip to fingertip. Some surgeons would see this is a self-portrait. If so, this the argument would appeal. Indeed such things do happen in art. One artist adds a brush stroke to paintings prepared by his school and then claims them as his own.
But, let’s look at this argument in more detail. I compare two of my favorite masterpieces. One is a Vermeer, “Girl with a Pearl Earring.” Vermeer is a Dutch painter and a master of light, texture, expression and tone. He is thought to have done 37 paintings in his life, each one (if you were able to obtain one now) would be worth the price of perhaps a small country. The other is a Caravaggio, “the Resurrection.” This sits in my favorite room in the Art Institute of Chicago. It is a masterpiece of light, perspective, tension and expressiveness.
There’s one problem though – there are no Caravaggio’s in Chicago! Art historians now think that this painting was actually done by the “Boy Francisco,” a young man who followed Caravaggio around late in his life. Now, what would one think if you had paid for a Caravaggio but received a “Boy Francisco,” or what would you think for example, if you were a government agency that paid for something by a master and was delivered something by a trainee? Think about that argument a bit.
Are you really the only one that can do that operation? An academic neurosurgeon’s job is to train the next generation to be better than we are. I do not want to be treated by the techniques of my teacher. I do not want my children to be treated by my trainees using my techniques – I want them to surpass me. That is our obligation as an academic neurosurgeon. What does that say about the brilliance argument? Consider the Caravaggio-ish painting by the “Boy Francisco” – it actually is a masterpiece! So my answer would be, if you cannot train others to do the operation with the same skill and results that you have, then you are not an academic neurosurgeon.
What About Efficiency?
W. Edwards Deming spent his 93 years teaching efficiency. His work on increasing quality while decreasing costs and increasing efficiency revolutionized the Japanese auto industry. His techniques, first adopted there in the rebuilding of Japan after World War II, have spread throughout the U.S. They are used by the surgeons as justification for the Indian cardiac surgeon doing 20 major cases per day. If Deming were alive today, I think he would be spinning in his grave because if you wish to increase efficiencies, you increase speed and turnover. My example is Juha Hernesniemi in Finland who masters turnover and speed to get his cases done and done on time. He does not double or triple the number of staff so that they can watch trainees slowly prepare things for you. There’s no efficiency in that program whatsoever except for you – the primary surgeon. So the question I ask is, just who is efficiency for?
Is This the Right Way to Learn?
Finally the education argument – “That’s the way I was trained.” Well, consider the following: If you put 100 children unsupervised in a room with paints, one of them may well turn out to be Picasso. zzThe other 99 will make a mess! But that is OK because paint is expendable. However, patients are not, and I certainly would not give you credit for training Picasso by leaving him alone.
Indeed, if you think your absence is your teaching method, then you are only fooling yourself. If the trainee’s participation is determined by the patient’s ability to pay, then it is certainly not education that is the base of that program. Your surgical care should match your advertising and your billing. If your advertising is “come to our institution to be treated by the greatest surgeons in the world” and they are treated by trainees, then you are not meeting that standard. It truly is an issue of informed consent. Many iterations of surgical care are appropriate as long as the patient is informed, knowledgeable, accepting and billed for what they get – no more and no less.
More definitions are needed now.
Informed Consent. Only 18 percent of patients in a Journal of the American Medical Association (JAMA) survey would consent to surgery where a resident acts as the operating surgeon, so we need more definitions. These are definitions pertinent to the solution:
- Primary attending surgeon – The person/faculty member who is responsible in total for the surgery being done
- Critical portion of an operation – The key portion unique to that case and necessary for the successful result defined by the surgeon
- Back-up attending surgeon – A faculty attending surgeon who would be readily available to fill in on the second case if something unplanned were to happen while you were in the other case
- Qualified practitioner – A qualified resident, nurse practitioner, etc. who is qualified to do the noncritical portion of the case that you designate
- Readily available – You or the back-up attending surgeon are in the same building and not involved in other critical procedures.
Where Do They Stand?
Next, let’s look at my distillation of the position state on concurrent surgery including that of the American College of Surgeons (ACS) and the University of Wisconsin Surgical Service Policy 1.25 as well as the American Board of Neurological Surgery (ABNS), AANS, Congress of Neurological Surgeons (CNS) and the Society of Neurological Surgeons (SNS) (2-4).. They say quite clearly the primary attending is responsible for the total care of the case and its outcome. The critical portion is key to the outcome and unique to the case. Concurrent surgeries overlapping the critical portions are not appropriate. Overlapping surgeries, where the non-critical portions overlap, could be appropriate if the non-critical portion is delegated to a qualified practitioner and another attending surgeon is identified, readily available, documented in the medical record and known to the patient. The patient must be informed.
Multidisciplinary operations – When two different cases are being done on the same patient by two different teams, such as ENT doing its procedure then neurosurgery does its procedure. You are not required to be present and could be doing other cases while the other team is working.
Procedure-related tasks – You are allowed to leave the operating room for things related to that operation (you need to go look at the pathology, talk to the family or have other tasks, such as radiology, which are related to the case at hand).
Unanticipated emergencies – In this case, you are doing a critical operation and four other patients come in from a crash – you do the best you can to get all four cases started while calling in four additional partners to help.
How do such policies actually work? At the University of Wisconsin, concurrent surgery is not allowed. In the past five years, a total of approximately 1 percent of cases overlap on an average of 15 minutes (this is for all surgical services). Thirteen of these cases over the past five years involve neurosurgery. We have a strict informed consent policy, yet are very busy, productive, fiscally sound and turnout excellent trainees that remain in high demand.
The Real Issues at Hand
So really, in the end, I think is this is actually an issue of informed consent. Communication – is the patient getting the service they think they will receive? How do I obtain informed consent? People will ask me if they can tape me giving informed consent because they have heard that I study this and I ask them, “Which time?” because I repeat the informed consent in different settings and different times for the elective cases until I am satisfied that the patient and family are knowledgeable and know what we are about to do. In that process, I include my team. I identify my residents and students by rank and title and explain how they participate in that patient’s care. When I do this, the family and patients welcome these trainees as an integral part of their care, with an understanding of the role that each will play.
The second issue is professionalism. One of the key aspects of a profession is self-regulation. It is important that we address a public misperception of what we are doing if we wish to maintain a self-definition of our specialty. If we lose that to government oversight, we lose a key part of the professionalism that defines neurosurgery. While well-informed, concurrent surgery may have had a place in the past, it is presently not supported by our professional societies. We must understand this issue in a forthright manner or we will lose self-regulation.
Finally, the role of the academic neurosurgeon as supervisor in education is to assure that patients are well served. But it is equally importantly that trainees grow and are allowed to surpass you. There is no way, no matter how brilliant you are, that you can care for all of the patients that need your care or your special operation, nor could you ever care for the ones in the future except by training people. That is the job of an academic neurosurgeon – to train people to care for the patients you cannot reach and the ones that have not even been born yet. Efficiency is a goal, but you must ask – does the plan for efficiency service your or your patients? The job of an academic neurosurgeon is not to enhance his or her own stature. In the end, academic surgery is not about you – it is about the patients you serve now and the ones your trainees will serve in the future.
4. Intraoperative responsibility of the primary neurosurgeon. (2016). American Association of Neurological Surgeons, American Board of Neurological Surgery, Congress of Neurological Surgeons and Society of Neurological Surgeons.
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