The State of Overlapping and Concurrent Surgery and the Next Steps

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Surgeons operating in two operating rooms at once has occurred for many decades. This is particularly the case in academic medical centers where residents or fellows, who are doctors-in-training, are delegated responsibility commensurate to their training while the surgeon operates in a separate operating room. There are two different definitions related to this practice. Overlapping surgery is when the surgeon is present for critical portions of each surgery while concurrent surgery is when the surgeon is only present for the critical portions of one surgery. CMS has found this to be appropriate up to a point. As long as the surgeon is present for the critical portions of each surgery, a surgeon is allowed to “run two rooms.

In 2015, the Boston Globe published an in depth report discussing the lack of patient awareness of concurrent and overlapping surgery as well as concerns and implications of this practice that were raised by a surgeon at Massachusetts General Hospital. This led to further investigation by the Senate Finance Committee at multiple institutions including the Cleveland Clinic. Further reports of this practice in Seattle have also surfaced.

The American College of SurgeonsAmerican Academy of Orthopedic SurgeonsAmerican Association of Neurological Surgeons, Association of American Medical Colleges and the American Hospital Association have concluded that overlapping surgery is acceptable while concurrent surgery is unacceptable. Additionally, if during an overlapping surgery a surgeon is not available for the other room a second surgeon must be designated to be immediately available to assist. The Mayo Clinic has found that overlapping surgeries at their institution have had the same 30 day complications as non-overlapping surgeries. A study of a national database has found similar results.

Though it is difficult to start this discussion with patients, studies regarding their opinions on overlapping surgery show 64.6% of patients would prefer to know if their surgeon has scheduled another surgery at the same time. Some hospitals have taken the first step to rectify these concerns and include this information in patient consents. This step should be taken nationally at all hospitals and surgical centers. Further public education should be undertaken to discuss the safety of overlapping surgery. The majority of physicians are compensated based on their productivity which is measured by relative value units (RVUs). The expected number of RVUs would need to be changed to accommodate regulations limiting concurrent or overlapping surgeries. Additionally, while concurrent surgery is not recommended by almost all surgical societies, further steps can be undertaken, such as research in the safety of certain surgeries booked as overlapping, change in productivity of surgeons, and access to surgical care.

3 Responses to “The State of Overlapping and Concurrent Surgery and the Next Steps”

  1. smruzycki Says:

    Thank you!

    It seems important that each institution develop a policy against concurrent surgery in keeping with their professional bodies. Following the example of the Mayo clinic, each institution should also continuously evaluate their own outcomes to ensure that surgeons are following this policy and that safety outcomes are non-inferior.

  2. thomaswilson2017 Says:

    A variety of things have to be considered when thinking about this topic, including patient safety, informed consent, delays in care, and standards of care. Regarding patient safety, within neurosurgery which is my field of practice, a variety of recent studies have demonstrated equivalent patient outcomes with overlapping and non-overlapping surgery (J Neurosurg. 2017 Jan 20:1-7; J Neurosurg. 2016 Dec 2:1-9; World Neurosurg. 2017 Apr;100:658-664; Neurosurgery. 2017 Feb 1;80(2):257-268). From personal experience, at teaching institutions, I do not think that portion of the case that the resident/fellow performs primarily changes much whether or not it is an overlapping case versus a non-overlapping case. Residents and fellows will be involved in the case to varying extents regardless of whether or not the attending surgeon has one or two rooms running. Furthermore, at least in my experience, the attending surgeon has always been available in the case of an emergency. Based on this, I think patient outcomes are unlikely to be different for overlapping and non-overlapping cases.

    With regard to informed consent, I think patients do have a right to know when residents and fellows will be involved in their care. Just as I think to perform appropriate informed consent involves telling the patient explicitly that the operation is being performed at a teaching hospital, I think it also requires informing the patient that their operation may be overlapping with another. The patient can then make an appropriate decision whether or not to proceed with surgery. I also think it is important to remember that this practice not only occurs at teaching institutions but also at private institutions where physician’s assistants play the same role as residents or fellows. Patients often come to a specific surgeon because of his or her reputation and outcomes. It is important to remember that that reputation and those outcomes were built and achieved at least in part due to the team around them that includes PA’s, residents, and fellows, not despite the team.

    The practice of overlapping surgery is common and many surgeons, particularly those with a good reputation and a track record for good outcomes are booked for months in advance, even with overlapping surgery. If overlapping surgeries are eliminated or reduced, it will severely impact access to these surgeons. As policies are created, it will be important for patient advocacy groups to consider any potential benefits of eliminating overlapping surgeries weighing it against the inevitable delays in care or reduced access to the best surgeons that will result.

    At this point, additional studies are coming out frequently on this topic. I do not think, however, enough data exists to call for national standards. We will likely reach that point in the not too distant future. In the meantime, I think it is incumbent upon each institution to put in place a logical and reasonable policy based on the available data, rather than a reactionary policy that occurs in response to sensationalistic individual cases.

  3. taramhansen Says:

    This is a very interesting practice that I wasn’t aware of before. I do agree that patients have a right to know if their surgeon practices this way but I think it should also come with a disclaimer stating that this is way the surgeon usually practices. Additionally, I wonder what happens if something unexpected happens during the critical period of the first surgery. It would be interesting to see how many surgeons or hospitals have policies in place in case of an emergency. I think the problem of concurrent surgeries ultimately arises from an overworked physician workforce. It may be better to spend the research money on researching that angle, since the practice of concurrent surgeries likely arose from there not being enough surgeons.

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