In 2016, the Boston Globe Spotlight Team highlighted the practice of senior surgeons monitoring more than one operating room at the same time. It was labeled “simultaneous surgery,” or “concurrent surgery.” In response, the public got angry. Patients were worried their surgeon simply wouldn’t be able to concentrate on their case. Surgeons were accused of greed and indifference. Even the Senate Finance Committee scrutinized, reviewed, and otherwise weighed in on the crusade. In the end, the panel called for a ban specifically on simultaneous surgery.
As a result of all this, hospitals and training programs around the country began cracking down on the practice, significantly reducing or even prohibiting senior surgeons from supervising more than one operating room at a time. But this sensational reaction is inappropriate and potentially damaging to both medical providers and patients.
As the chief resident of the neurosurgery service at the LSU Health Sciences center, I worry about my future residents’ ability to train effectively and efficiently if health services organizations seek to completely abolish overlapping surgery. It is a common way to maximize hospital resources and caregiving, and without it, the next generation of senior surgeons would be deprived of key opportunities to learn from their master technicians.
First, the term of simultaneous or concurrent surgery itself is fundamentally flawed. It implies that a surgeon performs two surgeries that start at exactly the same time, which is specifically what the Senate Finance Committee recommended against in its report. But this simply is not what occurs inside an operating room.
The proper term is “overlapping surgery”: overlap that comes in the logistics of setting up an operating room, inducing general anesthesia, opening or closing the surgical incision, and reviving a patient from general anesthesia. Neurosurgery, for example, is not just surgery “cut time.” It involves a host of specialized professionals, from anesthesiologists to nursing staff.
Data from the Massachusetts General Hospital showed that 37,000 surgical procedures were performed there in 2014—and only 3 percent of cases had any overlap when the actual case was underway. The remainder occurred while the patient was in the operating room before the incision was cut or after the incision was closed. Sometimes these periods of time can take hours, and patients should not have to wait if they don’t need to.
The process has yielded three distinct criticisms from its detractors: Is overlapping surgery safe? Isn’t the practice just greed? And don’t patients have a right to know?
First, yes, it is safe.
Separate academic studies released through the Mayo Clinic, Barrow Neurological Institute, Emory University, The University of California San Francisco, The University of Utah, and Massachusetts General Hospital have demonstrated that overlapping surgery poses no additional complication risk across thousands of patients. To date, there is only one study that shows a correlation between complications and overlapping surgery for patients undergoing hip surgery.
Second, no, it is not greed. Medicare already bans payment for cases where the two critical portions of a case are performed at the exact same time. Additionally, a new publication led by my colleague Anthony DiGiorgio in the journal Neurosurgery found that a large portion of the nearly 500 patients who underwent overlapping surgery in their series were those who needed urgent surgery. In their series, more than 25 percent of the patients undergoing overlapping surgery had no insurance, and nearly 40 percent had Medicaid. In Louisiana, Medicaid reimburses about 71 percent of what Medicare does and about 50 percent of what private insurance might reimburse for a given procedure. These are not income-generating procedures, but rather medically necessary procedures.
This is compounded by the fact that most of the academic training hospitals are Level I Trauma Centers—which take the most serious of cases—or tertiary referral centers. They receive very sick patients and very complex cases referred from other physicians. Patients with aneurysm ruptures, serious vehicular injuries, brain bleeds, and gunshot wounds are common in these hospitals. As such, these cases are never planned events. Previously, an overlapping surgery model would allow a complex, planned elective surgery to partially overlap with an urgent surgery. But if overlapping surgery is banned, then the urgent case may simply have to wait, if the only senior surgeon available is already in the middle of a separate procedure. Given the amount of time necessary to complete one surgery and prepare the operating room for the next, the trauma patient could be operated on at an undesirable time: later in the afternoon, for example (there are data to suggest this is far from ideal), or even the next day.
Already, the national governing body of physician training limits the number of hours physicians-in-training can work, even if they want to work more hours to learn their craft. Averaged over four weeks, doctors-in-training can’t work more than 80 hours per week. Without overlapping surgery, it’s obvious that cases would start later in the afternoon and subsequently go later into the evening—potentially causing trainees to prematurely approach their work restrictions.
Finally, patients do have an absolute right to know what is occurring during their surgery. But in one study, only 4 percent of patients understood the concept of overlapping surgery, and 86 percent thought they should be told who was going to be in the operating room before surgery. That’s unacceptable on the part of surgeons, who must do better informing their patients about their care ahead of time.
Patients should also appreciate that overlapping surgery allows more patients to receive care from a limited number of top professionals. Certain patients may very well choose not to have elective surgery in an overlapping fashion, but they may have to wait longer to have it. Market forces for hospital and physician selection would come into play.
Regardless of their decision, it is up to surgeons to provide the best quality of care to the most number of people possible. They must do this while simultaneously training the next generation of surgeons. Overlapping surgery is a traditional part of medical care that allows both to happen.
