AANS Neurosurgeon | Volume 29, Number 1, 2020


Concomitant Surgery

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Historically, the idea that surgical education involved a graduated increase in responsibility and that the professor used his or her discretion in determining at which point a given trainee required direct versus indirect responsibility was taken for granted. The surgeon, as captain of the ship, was trusted to make appropriate decisions regarding patient care, including the level of involvement of the residents and medical students . As the medical literature has suggested, patients cared for in teaching hospitals receive better care than those in private hospitals, so who would ever question such decision-making? 

The articles in the Boston Globe in December 2015 made the scales fall from the eyes, exposing episodes of care in which patients came to harm because of concurrent surgeries (1). More importantly, the lack of informed consent in those cases caused the public to question the sanctity of the physician-patient relationship. As a consequence, the Senate Finance Committee surveyed 20 U.S. teaching hospitals on this issue, leading to operational and policy changes in each of them (2). Likewise, the Department of Health and Human Services (HHS) redefined the reimbursement requirements for teaching hospitals treating Medicare and Medicaid patients, which include: 

  • The teaching physician must be physically present during all key or critical portions of the surgery and must be “immediately available” throughout the surgery.
  • The critical portion of two separate surgeries may not take place simultaneously.
  • If circumstances prevent the teaching physician’s presence immediately during any portion of the operation, another qualified surgeon must be immediately available to assist if needed.

The position statements by both the American College of Surgeons (ACS) and AANS define “immediate availability” as immediately reachable by electronic means (3). Furthermore, since the element of trust is the foundation of any physician-patient relationship, patients should be explicitly told before surgery of overlapping cases and should be informed following the surgery if the surgeon of record was out of the room for a portion of the operation. If a patient’s surgery requires a multi-disciplinary team, it should be clarified with the him or her that a given surgeon may be present by him or herself during a designated portion of the operation.

If asked, the public would be quick to acknowledge that no one wants a surgeon turned loose on society who has never performed an operation on his or her own. They would also be quick to understand that, in a teaching hospital, residents-in-training will be performing portions of their surgery at the discretion of the attending surgeon; but in the past, the assumption was that the surgeon would never jeopardize a patient’s safety.

Interestingly, until the Boston Globe articles, little had been written on whether safety might be compromised by overlapping surgeries. In the last year, a number of institutional reviews, such as the publication of Guan et al (Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases) in the (JNS) (4), have verified that overlapping surgery does not compromise safety and, in fact, is a means of better utilizing valuable operating room time. In their single-institution retrospective review, the authors scrutinized a year’s worth of surgical data from five neurosurgeons. They found no difference in the incidence of serious complications in overlapping surgeries compared to non-overlapping surgeries. 

That the articles by the Boston Globe caused policy makers, hospital associations, trade organizations and physicians to redefine overlapping surgeries, to publicly acknowledge that concomitant surgeries are not appropriate and to actively inform patients when residents-in-training will be performing portions of a patient’s surgery are all laudable. Sometimes it takes a wake-up call to make us reassess long-standing assumptions.

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

2.  Concurrent and overlapping surgeries: additional measures warranted. (2016). A Senate Finance Committee Report. 

3. AANS/ABNS/SNS/CNS position statement on intra-operative responsibility of the primary neurosurgeon. (2016). 

4.  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.


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