Cover Story

Concurrent surgery: Defining and implementing a safe practice

It has recently come into question whether concurrent surgery should be practiced and, if so, whether patients should be aware it is being performed. One of the first steps in answering these questions is to provide a specific definition for concurrent surgery.

“One of the important points is to understand the difference between concurrent surgery and overlapping surgery,” Gerald R. Williams Jr., MD, president of the American Academy of Orthopaedic Surgeons, told Orthopedics Today.

According to Williams, concurrent surgery is when some aspects of the critical portion of the operation are being done at the same time on two different patients. This is differentiated from overlapping or staggered surgeries, which occur when two operations overlap by a certain amount without the key portions overlapping.

Gerald R. Williams Jr., MD
Gerald R. Williams Jr., MD, recently weighed in on the practice of concurrent surgery. Williams applauded the updated Statement of Principles the American College of Surgeons issued, which was updated to include a clear definition of concurrent surgery.

Image: Cushman R

Felix H. Savoie, MD, of the Department of Orthopedics at Tulane University, said concurrent surgery is not common in orthopedic practices.

“If you are talking about two rooms running at exactly the same time, I do not think that is common at all,” he said. “If you are talking about staggered rooms, a completely different issue, I think that is common in busy practices because running one room is inefficient.”

Williams noted the controversy over this practice started a conversation that will ultimately regulate better patient care and safety.

“I cannot imagine there is a major institution in the United States not having discussions about protocols and policies around informed consent and policies with regarding to appropriateness and rules surrounding concurrent surgery,” he said.

Benefits of concurrent surgery

The American College of Surgeons (ACS) recently updated their Statements on Principles to expand what is appropriate and inappropriate regarding concurrent surgery. The document differentiates and defines concurrent or simultaneous surgery, overlapping surgery, multidisciplinary surgery and delegation to qualified practitioners.

“The Academy [American Academy of Orthopaedic Surgeons (AAOS)] strongly endorses the ACS consulting statement that has recently come out, and we applaud the ACS for taking this on,” Williams, who is also the John M. Fenlin Jr., MD professor of shoulder and elbow surgery at the Sidney Kimmel Medical College at Thomas Jefferson University, said. “I am sure it was a difficult decision for them, but I think that document indicates there are appropriate exceptions to the primary surgeon being in the OR from start to finish.”

In a recently published JAMA article, Michelle M. Mello, JD, PhD, and Edward H. Livingston, MD, noted concurrent surgery is not without risks, specifically “when responsibilities are not delegated to surgeons with appropriate skill and experience or the supervising surgeon is unable to reach the patient in time to prevent an unexpected crisis from escalating.” Despite these risks, the authors found several benefits of concurrent surgery, including the ability for surgical trainees to build their skills and experience.

“We are in a situation where we can all say ‘I want the doctor with 20 years of experience,’ but the reality is for somebody to get 20 years of experience, they have to start somewhere,” Robert T. Burks, MD, professor of orthopedic surgery at the University of Utah, told Orthopedics Today. “In teaching situations, you cannot graduate somebody and certify them as capable and ready to go out and take care of the public if they have never had opportunities in their training to do some aspects of these cases.”

Overlapping surgery

Williams noted using a team approach to overlapping surgery can be more efficient and save time while also opening access to patient care with specialized surgeons and programs.

“There is plenty of data to show high-volume centers that use a team approach typically have better outcomes than programs that do not,” he said. “Patients benefit from a highly specialized team that are with them all the time rather than having some members of the team leave at 3 o’clock in the afternoon because instead of being able to get rid of some of the turnover time and being efficient, you have to go one-by-one to an OR and you are there beyond the time they would be there.”

According to Savoie, who is also an Orthopedics Today Editorial Board member, physicians have greater overall satisfaction with running two ORs with two teams compared with running one OR with one team.

“When we did two room with two full teams, the nursing staff, the techs, even the janitors were happier,” Savoie said. “They felt they were not under so much pressure to clean the room as fast as possible.” He added not only is overlapping surgery more efficient, but the costs and quality improve as well.

Robert T. Burks, MD
Robert T. Burks

Overlapping surgery also gives the patient more time to speak with the anesthesiologist and surgeon before and after surgery. “[There] is more attention to detail in [two] rooms than one room where you are under pressure to change everything over and you do not have as much time to clean the room and get everything set up,” Savoie told Orthopedics Today. “So it benefits the patient in terms of comfort and timing and a slower pace, even though it is a faster pace for the surgeon.”

Documentation of time

One way the Massachusetts Medical Board is handling potential problems with concurrent surgery is by enacting a regulation that would require surgeons to document their time in and out of different ORs. According to James B. Rickert, MD, president of the Society for Patient Centered Orthopedics, these times are often undocumented.

Burks stated there are several ways to document surgeon times in and out of the OR, including dictating operation notes.

“Dictating your own operation notes is a way of saying you were there because you are dictating what happened,” he said. “Another way is for a doctor to say ‘I left the procedure at this point,’ [so] that would be another way of documenting when you are there. Nurses many times make notes on who is in the room or when a physician arrives or leaves, so nursing notes are another way of documenting when a surgeon is there and [their presence] for the critical part of the case.”

Patient consent

Besides helping to define the difference between concurrent and overlapping surgery, the ACS Statement on Principles also recommends all surgeons have an informed consent conversation with all patients about the nature of their illness, the nature of the proposed operation, the common complications associated with the surgery, any alternative forms of treatment and “the different types of qualified medical providers that will participate in their surgery (assistant attending surgeon, fellows, resident and interns, physician assistants, nurse practitioners, etc.) and their respective role explained.”

However, Williams noted there is no specific informed consent language that represents all surgeons in all hospitals because all “hospital systems and hospitals have their own rules about how informed consent should read,” as well as a number of locally applied rules.

“The rules around the practice of medicine both through the standpoint of regulations as well as malpractice, are locally different,” Williams said. “I do not think you could say there is a type of informed consent language that should be in every informed consent document about concurrent surgery in every hospital in the United States, but I think you could say there are principles that should be followed in every informed consent document that has to do with concurrent surgery.”

As the language for informed consent varies, Rickert said surgeons may not adequately tell patients they will be performing concurrent surgery during their procedure, which may be done for fear of losing an uncomfortable patient.

“I think there are instances where instead of just being frank with a patient, the doctor can use euphemisms to skirt over the fact that they are not going to be there [for part of the surgery],” Rickert said.

He added surgeons should be upfront with their patients and inform them if they perform concurrent surgery so patients have the opportunity to either become acquainted with the rest of the staff or find a surgeon who does not perform concurrent surgery if they are uncomfortable with it.

“Patients are 100% vulnerable during surgery and they have a right to choose who is going to be operating on them,” Rickert said.

Felix H. Savoie, MD
Felix H. Savoie

But telling patients they have your undivided attention, regardless of whether they have overlapping surgeries, may help ease patients’ minds, according to Savoie.

“There is nothing else in the world except that patient right then and doing what is best for them,” Savoie said. “I think that is the surgeon’s responsibility, that is the ethics of surgery and that cannot be violated in any way.”

Defining concurrent surgery is important because, according to Burks, concurrent surgery may not only be acceptable, but necessary in case of emergency.

“Imagine what happened in Boston hospitals right after the marathon bombing,” Burks said. “You have people hurt. You need to get them in an OR and you might have concurrent surgery going on, but you are doing it because you need to solve a problem.”

Even if a surgeon is not planning on performing concurrent surgery during a routine case, patients should still be informed of the process in the event a patient is brought in who needs emergency surgery and there are not enough attendants on staff.

Critical aspects of surgery

If a surgeon is not present for the critical part of the case for any reason, Williams noted it is illegal for that surgeon to bill for services in that case. In addition, patients should be made aware the surgeon was not present. According to David M. Glaser, JD, attorney with Fredrikson and Byron, Medicare provides specific instructions on submitting a bill for reimbursement when working with residents. These instructions state the attending surgeon needs to be present for the critical portion of the case in order to receive reimbursement. He added if a surgeon bills for a surgery in which the surgeon was not present for the key portion, it could be considered fraud.

“[Medicare] does not say what those key portions are,” Glaser, an Orthopedics Today Editorial Board member, said, “and it kind of leaves that to the discretion of the physician, though it is clear that opening and close are not considered to be key.”

Burks noted similar to the definition of concurrent surgery, what constitutes the critical aspect of the case may vary between surgeons. Williams said the attending surgeon is usually the one who defines the critical aspect of the case, and several hospitals have begun to keep track of what their surgeons would consider the key portions of common operations to avoid conflict and set standards. According to Rickert, while some surgeons believe the critical aspect begins from the incision into the fascia, the type of surgery could help determine the critical aspect of the case.

“If it is an ACL reconstruction, [the surgeon] might feel the critical aspects are drilling the tunnels and then placing the graft and the rest can be left to the fellow,” Rickert said. “I think for spine surgery, the exposure is often left to the fellow and then when it is time to put in the instrumentation or do the actual work around the spinal cord, that is considered a critical element of the surgery.”

Another area of debate includes who should be setting the safe boundary standards for concurrent surgery, according to Burks. Savoie said surgeons should be setting the standards for surgery in the hospital, as they are the only ones who know their limits, while Williams asserted boundaries should be set by multiple people on a hospital-by-hospital basis.

“[Safe boundaries] probably should be a multifactorial or multi-stakeholder situation, and I think it would be impossible to figure out what it was without some surgical input or nursing input,” Williams said.

According to Rickert, some individuals and patient advocacy groups contend surgeons should not set their own boundaries without guidelines.

“Patient safety groups would say we need to have standards patients can understand so they know how much of the surgery the doctor is going to be performing,” he said, “and it should not be based on intangibles like the mood or whim of the doctor.”

“I think there will be some guidelines or standards enacted inevitably. CMS or someone else will step in to determine that, and I think there will be some guidelines beyond whatever the doctor at the time says,” Rickert added.

Savoie said it may be difficult to legislate standards, especially those due to an ethical issue, unless concurrent surgery is banned entirely. He believes this will cause a rise in medical costs and affect the quality of patient care.

“[If good surgeons are] running two rooms, it is because they know it is not necessarily better for them, but better for the patient,” Savoie said. “I do not think there is any question that the folks I have seen who run two rooms who are good surgeons were under the best care. I think it is a reasonable thing to do and I would hate to see the government interfere in something they do not understand.”

Burks noted because the number of surgeons who break protocol are low, those surgeons should be dealt with directly instead of establishing one sweeping rule applicable to all surgeons.

“At the end of the day, you have to have some faith. You have to have some deference the surgeon is doing the right thing,” Burks said. – by Casey Tingle

Disclosures: Williams reports he holds stock in CrossCurrent Business Analytics, Force Therapeutics, ForMD, In Vivo Therapeutics and OBERD; receives research support from Synthasome and Tornier; receives intellectual property royalties from DJ Orthopedics, DePuy and IDMS; and receives research or financial support from DePuy and Wolters Kluwer Health - Lippincott Williams & Wilkins. Burks, Glaser, Rickert and Savoie report no relevant financial disclosures.

POINTCOUNTER 

Should there be a national protocol for concurrent surgery or should protocols be determined on a case-by-case basis?

POINT

National protocol

Concurrent surgery should be addressed at a local level, considering specific surgeon, case and hospital/surgery center factors.

Alexandra Page, MD
Alexandra Page

The health care battle cry for the past decade has been value, alebeit tempered by patient-centered care. Viewed through these lenses, while the tradition of concurrent surgeries offers a way to maximize access to high-quality surgical care, it should be considered in the context of specific cases rather than sweeping national reform. One model of high-value care has included assembling teams in which every member works at the top of his or her license or ability. As such, an operative team incorporating an assistant or training surgeon to perform routine positioning, exposure and closure facilitates optimal use of resources. This model, which progressively transfers responsibility as trainees gain surgical experience and expertise, ensures a future generation of skilled surgeons. But not every case, nor every surgeon, is right for concurrent surgeries.

Surgery has potential for the unexpected whether a surgeon runs one room or two rooms. The art of surgery comes more from the anticipation, prevention and response to complications that defy algorithmic solutions. The model of surgical training for the unexpected can be applied to protocols that understand the case, the patient and what could go wrong, and base the decision for concurrent surgery on these data, not national protocols.

Developing and applying a national protocol to such a nuanced process with many variables would result in cumbersome and complex rules. Further, implementing a national protocol would require diverting resources for monitoring and reporting. In many cases, implementation of national requirements, such as [Surgical Care Improvement Project] SCIP measures, fails to achieve the desired outcome. CMS has offered a framework on concurrent surgery, requiring a surgeon be present for the “critical or key portions of both operations” to bill for concurrent surgeries. Yet, despite identifying what constitutes “critical” defies ready definition, it would be required for thousands of potential operations if a blanket national protocol was implemented.

Practicing patient-centered care requires transparency if concurrent surgeries are anticipated. Clarifying the rationale and parameters for concurrent surgeries will serve our patients and profession, but can be most effectively and efficiently addressed based on the specifics of the surgeon and case rather than by national protocol. Factors to consider in local protocols may include the following:

  • Transparency: Clarification on the informed consent so the patient understands a surgery is performed as a team, led by the attending surgeon but with other surgeons assisting.
  • Case selection: Primary cases are typically amenable, revisions less so. Clarification of what represents the “critical” portion on a case-specific basis.
  • Primary surgeon: Surgeons with more predictable surgical times and/or cases may be better suited for concurrent cases.
  • Assistant surgeon: Parameters for a board-certified or board eligible assistant should be very different than for a PGY-2 resident.
  • Documentation: Including the presence of the primary surgeon as part of the operative record
  • Local resources: Availability of other surgeons, including cross-specialty for emergencies; room, equipment and anesthesia availability; case volume.

Alexandra Page, MD, is an orthopedic surgeon in San Diego, Calif.
Disclosure: Page reports no relevant financial disclosures.

COUNTER

Preoperative, postoperative concurrent care

The primacy of the physician-patient relationship is threatened by increasing pressures for productivity, of late primarily achieved through increased volume and efficiency. Relatively fixed capacities of facilities and attending surgeons have led to an increase in concurrent surgeries, a practice which has gathered recent attention. Support for such practices was summarized well by Peter Slavin, MD: outcomes and patient safety have been shown to be equivalent, and concurrent surgeries are an important component of teaching programs’ empowerment of senior residents and fellows. They allow our system to better learn how to function in the event of mass casualties, such as the terror attacks in Boston, an unfortunate reality of our times. National standards and regulations imposed by centralized planning would impair these legitimate functions and should be opposed. Nevertheless, if concurrent surgery is potentially to occur, it should be transparently communicated with all parties in accordance with the American Academy of Orthopaedic Surgeons Standards on Professionalism.

Thomas S. Boniface, MD
Thomas S. Boniface

We should also recognize these issues of concurrence extend beyond operative procedures. There has been an exponential increase in dependence on physician extenders in the preoperative and postoperative components of our care. It is outside the OR where we, as surgeons, should be performing the critical, patient-centric tasks of shared decision-making, evaluating not only the physical, technical and structural aspects of care, but also the psychosocial, emotional and cultural ones that have been shown to have stronger, more consistent relations to outcome than who may be holding the knife. We do a disservice to our patients, our communities and ourselves when we defer the nonoperative relationship and tasks to other members of the team.

Thomas S. Boniface, MD, is professor and chairman of the Department of Orthopaedic Surgery at Northeast Ohio Medical University.
Disclosure: Boniface reports no relevant financial disclosures.

It has recently come into question whether concurrent surgery should be practiced and, if so, whether patients should be aware it is being performed. One of the first steps in answering these questions is to provide a specific definition for concurrent surgery.

“One of the important points is to understand the difference between concurrent surgery and overlapping surgery,” Gerald R. Williams Jr., MD, president of the American Academy of Orthopaedic Surgeons, told Orthopedics Today.

According to Williams, concurrent surgery is when some aspects of the critical portion of the operation are being done at the same time on two different patients. This is differentiated from overlapping or staggered surgeries, which occur when two operations overlap by a certain amount without the key portions overlapping.

Gerald R. Williams Jr., MD
Gerald R. Williams Jr., MD, recently weighed in on the practice of concurrent surgery. Williams applauded the updated Statement of Principles the American College of Surgeons issued, which was updated to include a clear definition of concurrent surgery.

Image: Cushman R

Felix H. Savoie, MD, of the Department of Orthopedics at Tulane University, said concurrent surgery is not common in orthopedic practices.

“If you are talking about two rooms running at exactly the same time, I do not think that is common at all,” he said. “If you are talking about staggered rooms, a completely different issue, I think that is common in busy practices because running one room is inefficient.”

Williams noted the controversy over this practice started a conversation that will ultimately regulate better patient care and safety.

“I cannot imagine there is a major institution in the United States not having discussions about protocols and policies around informed consent and policies with regarding to appropriateness and rules surrounding concurrent surgery,” he said.

Benefits of concurrent surgery

The American College of Surgeons (ACS) recently updated their Statements on Principles to expand what is appropriate and inappropriate regarding concurrent surgery. The document differentiates and defines concurrent or simultaneous surgery, overlapping surgery, multidisciplinary surgery and delegation to qualified practitioners.

“The Academy [American Academy of Orthopaedic Surgeons (AAOS)] strongly endorses the ACS consulting statement that has recently come out, and we applaud the ACS for taking this on,” Williams, who is also the John M. Fenlin Jr., MD professor of shoulder and elbow surgery at the Sidney Kimmel Medical College at Thomas Jefferson University, said. “I am sure it was a difficult decision for them, but I think that document indicates there are appropriate exceptions to the primary surgeon being in the OR from start to finish.”

In a recently published JAMA article, Michelle M. Mello, JD, PhD, and Edward H. Livingston, MD, noted concurrent surgery is not without risks, specifically “when responsibilities are not delegated to surgeons with appropriate skill and experience or the supervising surgeon is unable to reach the patient in time to prevent an unexpected crisis from escalating.” Despite these risks, the authors found several benefits of concurrent surgery, including the ability for surgical trainees to build their skills and experience.

“We are in a situation where we can all say ‘I want the doctor with 20 years of experience,’ but the reality is for somebody to get 20 years of experience, they have to start somewhere,” Robert T. Burks, MD, professor of orthopedic surgery at the University of Utah, told Orthopedics Today. “In teaching situations, you cannot graduate somebody and certify them as capable and ready to go out and take care of the public if they have never had opportunities in their training to do some aspects of these cases.”

Overlapping surgery

Williams noted using a team approach to overlapping surgery can be more efficient and save time while also opening access to patient care with specialized surgeons and programs.

PAGE BREAK

“There is plenty of data to show high-volume centers that use a team approach typically have better outcomes than programs that do not,” he said. “Patients benefit from a highly specialized team that are with them all the time rather than having some members of the team leave at 3 o’clock in the afternoon because instead of being able to get rid of some of the turnover time and being efficient, you have to go one-by-one to an OR and you are there beyond the time they would be there.”

According to Savoie, who is also an Orthopedics Today Editorial Board member, physicians have greater overall satisfaction with running two ORs with two teams compared with running one OR with one team.

“When we did two room with two full teams, the nursing staff, the techs, even the janitors were happier,” Savoie said. “They felt they were not under so much pressure to clean the room as fast as possible.” He added not only is overlapping surgery more efficient, but the costs and quality improve as well.

Robert T. Burks, MD
Robert T. Burks

Overlapping surgery also gives the patient more time to speak with the anesthesiologist and surgeon before and after surgery. “[There] is more attention to detail in [two] rooms than one room where you are under pressure to change everything over and you do not have as much time to clean the room and get everything set up,” Savoie told Orthopedics Today. “So it benefits the patient in terms of comfort and timing and a slower pace, even though it is a faster pace for the surgeon.”

Documentation of time

One way the Massachusetts Medical Board is handling potential problems with concurrent surgery is by enacting a regulation that would require surgeons to document their time in and out of different ORs. According to James B. Rickert, MD, president of the Society for Patient Centered Orthopedics, these times are often undocumented.

Burks stated there are several ways to document surgeon times in and out of the OR, including dictating operation notes.

“Dictating your own operation notes is a way of saying you were there because you are dictating what happened,” he said. “Another way is for a doctor to say ‘I left the procedure at this point,’ [so] that would be another way of documenting when you are there. Nurses many times make notes on who is in the room or when a physician arrives or leaves, so nursing notes are another way of documenting when a surgeon is there and [their presence] for the critical part of the case.”

Patient consent

Besides helping to define the difference between concurrent and overlapping surgery, the ACS Statement on Principles also recommends all surgeons have an informed consent conversation with all patients about the nature of their illness, the nature of the proposed operation, the common complications associated with the surgery, any alternative forms of treatment and “the different types of qualified medical providers that will participate in their surgery (assistant attending surgeon, fellows, resident and interns, physician assistants, nurse practitioners, etc.) and their respective role explained.”

However, Williams noted there is no specific informed consent language that represents all surgeons in all hospitals because all “hospital systems and hospitals have their own rules about how informed consent should read,” as well as a number of locally applied rules.

“The rules around the practice of medicine both through the standpoint of regulations as well as malpractice, are locally different,” Williams said. “I do not think you could say there is a type of informed consent language that should be in every informed consent document about concurrent surgery in every hospital in the United States, but I think you could say there are principles that should be followed in every informed consent document that has to do with concurrent surgery.”

PAGE BREAK

As the language for informed consent varies, Rickert said surgeons may not adequately tell patients they will be performing concurrent surgery during their procedure, which may be done for fear of losing an uncomfortable patient.

“I think there are instances where instead of just being frank with a patient, the doctor can use euphemisms to skirt over the fact that they are not going to be there [for part of the surgery],” Rickert said.

He added surgeons should be upfront with their patients and inform them if they perform concurrent surgery so patients have the opportunity to either become acquainted with the rest of the staff or find a surgeon who does not perform concurrent surgery if they are uncomfortable with it.

“Patients are 100% vulnerable during surgery and they have a right to choose who is going to be operating on them,” Rickert said.

Felix H. Savoie, MD
Felix H. Savoie

But telling patients they have your undivided attention, regardless of whether they have overlapping surgeries, may help ease patients’ minds, according to Savoie.

“There is nothing else in the world except that patient right then and doing what is best for them,” Savoie said. “I think that is the surgeon’s responsibility, that is the ethics of surgery and that cannot be violated in any way.”

Defining concurrent surgery is important because, according to Burks, concurrent surgery may not only be acceptable, but necessary in case of emergency.

“Imagine what happened in Boston hospitals right after the marathon bombing,” Burks said. “You have people hurt. You need to get them in an OR and you might have concurrent surgery going on, but you are doing it because you need to solve a problem.”

Even if a surgeon is not planning on performing concurrent surgery during a routine case, patients should still be informed of the process in the event a patient is brought in who needs emergency surgery and there are not enough attendants on staff.

Critical aspects of surgery

If a surgeon is not present for the critical part of the case for any reason, Williams noted it is illegal for that surgeon to bill for services in that case. In addition, patients should be made aware the surgeon was not present. According to David M. Glaser, JD, attorney with Fredrikson and Byron, Medicare provides specific instructions on submitting a bill for reimbursement when working with residents. These instructions state the attending surgeon needs to be present for the critical portion of the case in order to receive reimbursement. He added if a surgeon bills for a surgery in which the surgeon was not present for the key portion, it could be considered fraud.

“[Medicare] does not say what those key portions are,” Glaser, an Orthopedics Today Editorial Board member, said, “and it kind of leaves that to the discretion of the physician, though it is clear that opening and close are not considered to be key.”

Burks noted similar to the definition of concurrent surgery, what constitutes the critical aspect of the case may vary between surgeons. Williams said the attending surgeon is usually the one who defines the critical aspect of the case, and several hospitals have begun to keep track of what their surgeons would consider the key portions of common operations to avoid conflict and set standards. According to Rickert, while some surgeons believe the critical aspect begins from the incision into the fascia, the type of surgery could help determine the critical aspect of the case.

“If it is an ACL reconstruction, [the surgeon] might feel the critical aspects are drilling the tunnels and then placing the graft and the rest can be left to the fellow,” Rickert said. “I think for spine surgery, the exposure is often left to the fellow and then when it is time to put in the instrumentation or do the actual work around the spinal cord, that is considered a critical element of the surgery.”

PAGE BREAK

Another area of debate includes who should be setting the safe boundary standards for concurrent surgery, according to Burks. Savoie said surgeons should be setting the standards for surgery in the hospital, as they are the only ones who know their limits, while Williams asserted boundaries should be set by multiple people on a hospital-by-hospital basis.

“[Safe boundaries] probably should be a multifactorial or multi-stakeholder situation, and I think it would be impossible to figure out what it was without some surgical input or nursing input,” Williams said.

According to Rickert, some individuals and patient advocacy groups contend surgeons should not set their own boundaries without guidelines.

“Patient safety groups would say we need to have standards patients can understand so they know how much of the surgery the doctor is going to be performing,” he said, “and it should not be based on intangibles like the mood or whim of the doctor.”

“I think there will be some guidelines or standards enacted inevitably. CMS or someone else will step in to determine that, and I think there will be some guidelines beyond whatever the doctor at the time says,” Rickert added.

Savoie said it may be difficult to legislate standards, especially those due to an ethical issue, unless concurrent surgery is banned entirely. He believes this will cause a rise in medical costs and affect the quality of patient care.

“[If good surgeons are] running two rooms, it is because they know it is not necessarily better for them, but better for the patient,” Savoie said. “I do not think there is any question that the folks I have seen who run two rooms who are good surgeons were under the best care. I think it is a reasonable thing to do and I would hate to see the government interfere in something they do not understand.”

Burks noted because the number of surgeons who break protocol are low, those surgeons should be dealt with directly instead of establishing one sweeping rule applicable to all surgeons.

“At the end of the day, you have to have some faith. You have to have some deference the surgeon is doing the right thing,” Burks said. – by Casey Tingle

Disclosures: Williams reports he holds stock in CrossCurrent Business Analytics, Force Therapeutics, ForMD, In Vivo Therapeutics and OBERD; receives research support from Synthasome and Tornier; receives intellectual property royalties from DJ Orthopedics, DePuy and IDMS; and receives research or financial support from DePuy and Wolters Kluwer Health - Lippincott Williams & Wilkins. Burks, Glaser, Rickert and Savoie report no relevant financial disclosures.

PAGE BREAK

POINTCOUNTER 

Should there be a national protocol for concurrent surgery or should protocols be determined on a case-by-case basis?

POINT

National protocol

Concurrent surgery should be addressed at a local level, considering specific surgeon, case and hospital/surgery center factors.

Alexandra Page, MD
Alexandra Page

The health care battle cry for the past decade has been value, alebeit tempered by patient-centered care. Viewed through these lenses, while the tradition of concurrent surgeries offers a way to maximize access to high-quality surgical care, it should be considered in the context of specific cases rather than sweeping national reform. One model of high-value care has included assembling teams in which every member works at the top of his or her license or ability. As such, an operative team incorporating an assistant or training surgeon to perform routine positioning, exposure and closure facilitates optimal use of resources. This model, which progressively transfers responsibility as trainees gain surgical experience and expertise, ensures a future generation of skilled surgeons. But not every case, nor every surgeon, is right for concurrent surgeries.

Surgery has potential for the unexpected whether a surgeon runs one room or two rooms. The art of surgery comes more from the anticipation, prevention and response to complications that defy algorithmic solutions. The model of surgical training for the unexpected can be applied to protocols that understand the case, the patient and what could go wrong, and base the decision for concurrent surgery on these data, not national protocols.

Developing and applying a national protocol to such a nuanced process with many variables would result in cumbersome and complex rules. Further, implementing a national protocol would require diverting resources for monitoring and reporting. In many cases, implementation of national requirements, such as [Surgical Care Improvement Project] SCIP measures, fails to achieve the desired outcome. CMS has offered a framework on concurrent surgery, requiring a surgeon be present for the “critical or key portions of both operations” to bill for concurrent surgeries. Yet, despite identifying what constitutes “critical” defies ready definition, it would be required for thousands of potential operations if a blanket national protocol was implemented.

Practicing patient-centered care requires transparency if concurrent surgeries are anticipated. Clarifying the rationale and parameters for concurrent surgeries will serve our patients and profession, but can be most effectively and efficiently addressed based on the specifics of the surgeon and case rather than by national protocol. Factors to consider in local protocols may include the following:

  • Transparency: Clarification on the informed consent so the patient understands a surgery is performed as a team, led by the attending surgeon but with other surgeons assisting.
  • Case selection: Primary cases are typically amenable, revisions less so. Clarification of what represents the “critical” portion on a case-specific basis.
  • Primary surgeon: Surgeons with more predictable surgical times and/or cases may be better suited for concurrent cases.
  • Assistant surgeon: Parameters for a board-certified or board eligible assistant should be very different than for a PGY-2 resident.
  • Documentation: Including the presence of the primary surgeon as part of the operative record
  • Local resources: Availability of other surgeons, including cross-specialty for emergencies; room, equipment and anesthesia availability; case volume.

Alexandra Page, MD, is an orthopedic surgeon in San Diego, Calif.
Disclosure: Page reports no relevant financial disclosures.

COUNTER

Preoperative, postoperative concurrent care

The primacy of the physician-patient relationship is threatened by increasing pressures for productivity, of late primarily achieved through increased volume and efficiency. Relatively fixed capacities of facilities and attending surgeons have led to an increase in concurrent surgeries, a practice which has gathered recent attention. Support for such practices was summarized well by Peter Slavin, MD: outcomes and patient safety have been shown to be equivalent, and concurrent surgeries are an important component of teaching programs’ empowerment of senior residents and fellows. They allow our system to better learn how to function in the event of mass casualties, such as the terror attacks in Boston, an unfortunate reality of our times. National standards and regulations imposed by centralized planning would impair these legitimate functions and should be opposed. Nevertheless, if concurrent surgery is potentially to occur, it should be transparently communicated with all parties in accordance with the American Academy of Orthopaedic Surgeons Standards on Professionalism.

Thomas S. Boniface, MD
Thomas S. Boniface

We should also recognize these issues of concurrence extend beyond operative procedures. There has been an exponential increase in dependence on physician extenders in the preoperative and postoperative components of our care. It is outside the OR where we, as surgeons, should be performing the critical, patient-centric tasks of shared decision-making, evaluating not only the physical, technical and structural aspects of care, but also the psychosocial, emotional and cultural ones that have been shown to have stronger, more consistent relations to outcome than who may be holding the knife. We do a disservice to our patients, our communities and ourselves when we defer the nonoperative relationship and tasks to other members of the team.

Thomas S. Boniface, MD, is professor and chairman of the Department of Orthopaedic Surgery at Northeast Ohio Medical University.
Disclosure: Boniface reports no relevant financial disclosures.