Double-booking. Concurrent surgery. Procedural overlap. However it is named, the once clandestine practice is now under public scrutiny. The ripples of the Boston Globe exposé have spurred a more open discussion regarding the established practice. In the setting of modern day medicine, with shrinking reimbursements and rising costs, improving efficiency and productivity is essential. Overlapping surgery is a safe, effective method to achieve these goals. It is prudent not to pass judgment on such a long-standing, widely accepted practice without looking at both sides of the debate.
Patient safety and lack of regulation lie at the heart of the double-booking critic’s argument. As surgeons, we have an obligation to ensure the welfare of our patients. From the moment we recited the Hippocratic oath, we pledged to abstain from doing harm. The practice of procedural overlap does not violate our promise. With appropriate regulations and restrictions, concurrent surgery can be performed efficiently and effectively, without undermining patient well-being.
The Center for Medicare and Medicaid Services (CMS) has strict rules regarding billing for two overlapping surgeries. In Transmittal 2303 dated September 14, 2011, CMS clarified the use of residents in multiple procedures. The attending surgeon must be present during the critical portions of both cases, and when the critical portions of one procedure are completed, the surgeon may then begin a second procedure. Moreover, if the surgeon is not present during non-critical portions of the procedure, a second qualified surgeon must be immediately available to assist the resident physician, if needed. In the situation of three concurrent cases, the surgeon is not payable under the physician fee schedule. By taking on a supervisory role over the resident physicians during three concurrent procedures rather than performing a direct physician service, the surgeon is precluded from billing Medicare for the overlapping procedures.
Three years prior to the Boston Globe report, Massachusetts General Hospital (MGH) implemented one of the strongest overlapping surgery policies in the nation. Expanding upon CMS rules, MGH approved stringent guidelines regarding the perioperative policy for surgical staffing of two concurrent operating rooms. When running two rooms, surgeons must be present for critical portions of the case. At all times, their presence is mandated specifically within the operating suite. The evaluation of patients in clinic or completion of work in the office during concurrent procedures is forbidden. The guidelines do, however, recognize that surgeons are sometimes faced with extenuating circumstances. For example, coincident emergency procedures performed while on-call are exempt from strict regulation.
The policy on overlapping surgery implemented by MGH also elaborated on the issue of informed consent. It seems obvious that informed consent at any teaching hospital implicitly encompasses resident involvement in patient care. Nevertheless, MGH requires the role of the teaching surgeon to be discussed at length with each patient and their family prior to the operative procedures. Even in the two cases highlighted by the Boston Globe, an internal investigative report revealed that the informed consent signed by patients indicated that a team of medical professionals would be involved in the surgery and that their surgeon would be present for all critical parts of the procedure.
Despite the presentation by the media, the practice of overlapping surgeries was developed with the intention of improving patient access to care. There is a shortage of doctors and an even greater shortage of specialty surgeons across the country. The ability to perform concurrent procedures during daytime hours reduces the surgical wait time for in-demand surgeons. Running operating rooms in series is a poor utilization of surgeon resource, as the majority of time is spent in non-critical portions of the case.
Tenderly familiar to all of us, operating room turnover and preparation is time consuming. Starting with the interview in the preoperative area and concluding with surgical incision, the process can span hours, particularly in complex cases. During this time, anesthesia optimizes the patient and secures the airway while the operative staff ensures equipment availability and sterility. The room preparation for an operative case is similar to a pilot checklist prior to take-off. Procedures are done in distinct, sequential order to prevent lapses in patient care. Although this period is essential for operative success, members of the surgical team perform many of these steps. The attending surgeon is required only after anesthetic induction, surgical prep and sterile draping. The practice of overlapping procedures minimizes the idle time of our most talented surgeons. Abandonment of the system will only decrease the total number of patients possibly benefiting from the surgeon’s expert care.
In addition to improving access to care, concurrent operating rooms implement a graduated responsibility model for medical training. Graduated autonomy in the operating room is a fundamental part of surgical resident and fellow apprenticeship. As a society, it is important to recognize that this training is integral to the maturation of our next generation of surgeons. There is a limit to the amount of skill acquisition gained through observation. Although trainees need not perform critical parts of the procedure alone, performing surgery under a graduated supervision model is beneficial, as long as patient care is not compromised.
Unfortunately, there is a paucity of data in the literature regarding safety in the practice of procedural overlap. However, some of the early reports are promising. In a presentation at the annual meeting of the American Academy of Thoracic Surgeons in 2014, Yount et al. reported on 1748 cardiac and 1800 general thoracic surgery cases in which the attending surgeon was either running single or concurrent operating rooms. There were no statistically significant differences in observed or risk-adjusted outcomes in any category studied.
Furthermore, MGH performed an internal review of outcomes for procedural overlap in response to the Boston Globe article. During the clinical year of 2014, MGH performed 36,747 surgical cases, and less than 1% (324 operations) had 30 minutes or more of overlap time. Quality outcomes were assessed using standard National Surgical Quality Improvement Program (NSQUIP) definitions. After a chart review by trained, audited reviewers, no differences were found in quality outcomes between the single and concurrent operating room groups.
In summary, procedural overlap is a long-standing practice in academic medicine that facilitates patient access to excellent care. When bad outcomes occur, it is easy to blame a general practice, such as concurrent surgery, rather than determine the root cause of the problem. With the proper rules and regulations in place, procedural overlap allows for safe, efficient patient care, without sacrificing the training required for our next generation of surgical leaders.
Image credit: U.S. Navy licensed in the public domain.